Senior Pet ChecklistOwners Name* First Last Species* Canine FelinePets Name*Weight gain? Yes NoWhen did problem begin?Weight loss? Yes NoWhen did problem begin?Appetite increase? Yes NoWhen did problem begin?Appetite decrease? Yes NoWhen did problem begin?Vomiting? Yes NoWhen did problem begin?Diarrhea? Yes NoWhen did problem begin?Colitis (stool with mucus or blood) ? Yes NoWhen did problem begin?Constipation/difficult defecation? Yes NoWhen did problem begin?Increased drinking? Yes NoWhen did problem begin?Increased urine? Yes NoWhen did problem begin?Coughing? Yes NoWhen did problem begin?Weakness after exercise? Yes NoWhen did problem begin?Panting? Yes NoWhen did problem begin?Lumps/tumors? Yes NoWhen did problem begin?Skin problems? Yes NoWhen did problem begin?Describe? Yes NoWhen did problem begin?Bad breath/sore gums/difficulty chewing? Yes NoWhen did problem begin?Muscle tremors/shaking? Yes NoWhen did problem begin?Weakness/incoordination? Yes NoWhen did problem begin?Difficulty climbing stairs/increased stiffness? Yes NoWhen did problem begin?Diminished vision? Yes NoWhen did problem begin?Diminished hearing? Yes NoWhen did problem begin?Housesoiling Urine horizontal surface Urine vertical surface Bowel movement Urinary incontinence Indoor elimination in view of family Goes outdoors, eliminates indoors on return Elimination in crate or sleeping areaWhen did you first notice the problem(s)?Impaired learning/memory Decreased ability to work Forgets name/commands/previously learned tasks Decreased recognition of familiar people/animalsWhen did you first notice the problem(s)?Social: Decreased interest in petting/affection Decreased tolerance of handling More possessive Increased need or demand for affection/attention Problems with social relationships with other petsWhen did you first notice the problem(s)?Disorientation Gets lost Confused Goes to wrong side of door Can’t find dropped food Can’t maneuver around obstaclesWhen did you first notice the problem(s)?Anxiety/aggression Decreased tolerance of being left alone Increased irritability Restless/agitated Anxiety Can’t maneuver around obstacles Fearful Phobias AggressionWhen did you first notice the problem(s)?Purposeless/repetitive activity Vocal (whining, barking) Paces Circles Licks Stares into space Self-trauma Sucking HallucinatesWhen did you first notice the problem(s)?Sleep – wake cycles Wakes at night/restless sleep Decreased activity during the day/sleeps moreWhen did you first notice the problem(s)?Apathy/depression Less reactive Listless Decreased interest in food Decreased self-groomingWhen did you first notice the problem(s)?Other problems/concerns (or use this space to describe any of the above in more detail)List medications, diet or supplements your pet is taking:Has your pet been previously diagnosed as having any medical problems? Y/N Describe:CAPTCHAΔ
