SENIOR PET HEALTH QUESTIONNAIRE

Our pets have a relatively short lifespan compared to humans and the ageing process can progress quite rapidly. A dog is considered senior from 7 years of age and a cat from 9 years.

Early detection and management of certain conditions such as cancer, cardiac disease, diabetes, thyroid disease, osteoarthritis and dental disease, gives your pet a better chance of successful management.

Please complete this questionnaire to help us best understand your pet's health needs.

Client Details

Client first name

Client last name

Phone number

Email address

Address

Pet Details

Animal name

Animal species (e.g. dog, cat)

Animal breed

Animal sex (e.g. male, female)

Animal age/DoB

Animal microchip

EYE HEALTH

Please select from the following with regard to the eye health of your pet.
   Not aware of any problems
   Occasional discharge
   Frequent discharge
   Redness
   Greyish-blue eyes
   Rubbing at eyes
   Bumping into things
   Other

Other:

EAR HEALTH

Other:

MOUTH HEALTH

Please select from the following with regard to the mouth health of your pet.
   Not aware of any problems
   Bad breath
   Pawing at mouth
   Difficulty eating
   Broken tooth
   Other

Other:

SKIN HEALTH

Other:

JOINT HEALTH & MOBILITY

Please select from the following with regard to the joint health and mobility of your pet.
   Not aware of any problems
   Stiffness
   Lameness
   Difficulty rising or moving upstairs
   Lost interest in exercise or play
   Other

Other:

EATING & DRINKING

Please select from the following with regard to the eating and drinking habits of your pet.
   Not aware of any problems
   Eating or drinking less than last year
   Eating or drinking more than last year
   Has become fussy
   Eats on and off
   Other

Other:

BEHAVIOR

Please select from the following with regard the behavior of your pet
   Not aware of any problems
   Confusion or disorientation
   Less interation with the family
   Changes in sleep pattern
   Loss of housetraining
   Changes in sleep pattern
   Barking or howling for no reason
   Other

Other:

OVERALL HEALTH

Apart from the changes described above, please describe any other health concerns.

By submitting this form, I acknowledge that I am the owner or agent representing the pet named above and that the information here is true and correct.

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