Senior Pet Questionnaire

Senior Pet Questionnaire

Douds Veterinary Hospital
Owner's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Pet's Name
Do you have an upcoming appointment with us?
If so, please tell us the date and time
If this is your first visit, is this your first pet?

NoYesNot my first visit
Are you aware that pet insurance is available?

NoNo, tell me moreYes
Has your pet been microchipped?

NoNo, but I am interestedYes
Are you planning on boarding or grooming your pet within the next 6 months?

NoYes
Reason for your pet's visit?
Annual exam & vaccines, or another reason
Has your pet been seen for the same condition recently?
No, or if yes when?
Are your pet's vaccinations up to date?

NoYesDon't know
Is your pet spayed or neutered?

NoYesDon't know
Has your pet's stool been checked for parasites within the last 6 months?

NoYesDon't know
Have you seen any worms in your pet's stool?
No, or if yes, please describe.
Is your pet on heartworm prevention?

NoYes, year roundYes, part of the year
What heartworm product(s) do you use?
What day of the month do you give the heartworm prevention?
Is your pet on flea prevention?

NoYes, year roundYes, part of the year
What flea prevention product(s) do you use?
Has your pet had any illness or injury within the last 30 days?
No, or if yes, please describe
Is your pet currently on any medications?
No, or if yes, please list
Any known allergies to drugs/medications?
No, or if yes, please list
What dental care do you provide at home and how often?
What do you feed your pet?
List brand and amount
What treats do you feed your pet?
What table scraps do you feed your pet?
Does your pet have any food intolerances?
No, or if yes, please describe
Did your pet eat this morning?

NoYes
Have you noticed any of the following?

Check all that apply
Change in appetite:

Eating moreEating less
Changes in weight:

Weight lossWeight gain
Change in water intake:

Drinking moreDrinking less
Change in urinations:

Increased amountDecreased amountUrinating more frequently
Having accidents in the house:

Urinating indoorsDefecating indoors
Strains to urinate of defecate:

Strains to urinateStrains to defecate
Diarrhea:

Consistency of the stool is softConsistency of the stool is liquid
Stool contains:

BloodMucusHairForegn material (see below)
If foregn material, please describe:
Vomiting. Vomitus contains:

FoodHairBloodFluid (see below)Foreign material (see below)
Describe fluid or foreign material:
Color of fluid or description of foreign material
Scooting?

YesNo
Change in skin or hair coat:
Explain
Scratching, rubbing, chewing, or licking:
Where?
Change in energy level:

Decreased energyIncreased energy
Breathing issues:

Coughing or difficulty breathingExcessive pantingSneezing
Lumps or bumps that need examined:
Please describe location
Unusual discharge:
Describe
Bad breath?

YesNo
Difficulty seeing or hearing:

Vision problemHearing problem
Movement issues:

Difficulty climbing stairsDifficulty jumping up
Increased stiffness or limping. If so, which leg(s)?

Right frontRight rearLeft frontLeft rear
Change in activity level:

Increased activityDecreased activity
Circling or repetitive movements:
Please explain
Confusion or disorientation:

YesNo
Excessive vocalization:

YesNo
Change in interaction with family members:

Interacting moreInteracting less
Change in sleeping patterns:

Sleeping moreSleeping less
Is your pet having any other problems or issues that you would like to discuss with the doctor at your appointment?
Thank you for providing this information! Although we may not be able to address all of your pet's health concerns in this one appointment, we value this information as a tool to help keep your pet healthy and happy in future visits!
Should be Empty:

Senior Pet Questionnaire

Have you noticed any of the following?