Senior Pet History Worksheet
Pet's Name
*
Owner Name
*
First Name
Last Name
Email
*
example@example.com
Water Consumption
Increased
Decreased
Unchanged
Comments on your pet's water consumption
Food Consumption
Increased
Decreased
Unchanged
Trouble Chewing Hard Food
Yes
No
Only likes canned food now
Yes
No
Lack of interest in diet
Yes
No
Appears to have gained weight
Yes
No
Appears to have lost weight
Yes
No
Comments on your pet's food consumption
Has your pet's urination
Increased
Decreased
Comments on your pet's urination
Straining to defecate?
Yes
No
Comments on your pet's defecation
Loose Stool?
Yes
No
Comments on your pet's stool
Blood in stool?
Yes
No
Comments on blood in your pet's stool
Suddenly defecating indoors?
Yes
No
Comments on defecating indoors
Slow to stand when sitting/laying?
Yes
No
Comments on standing or sitting
Seems “stiff” in the mornings/anytime?
Yes
No
Stiffness in a particular area?
Yes
No
Comments on stiffness including where your pet appears stiff
Struggles to sit/lay?
Yes
No
Discomfort when attempting to to sit/lay?
Yes
No
Comments on Sitting/Laying:
Needs help getting up?
Yes
No
Comments on needing help getting up:
Is your pet still able to jump up on furniture?
Yes
No
Comments on jumping on furniture:
Struggles with stairs?
Yes
No
Comments on struggling with the stairs
Appears lost or confused?
Yes
No
Comments on appearing lost or confused
Less responsive to commands?
Yes
No
Comments on responsiveness
Increased sleeping?
Yes
No
Comments on increased sleeping
Decreased interaction with family?
Yes
No
Comments on interaction with family:
Trouble tolerating exercise?
Yes
No
Comments on tolerating exercise:
Coughing?
Yes
No
Any pattern with respect to coughing?
Sneezing?
Yes
No
Any pattern with respect to sneezing?
Increased effort to breathe?
Yes
No
Increased panting?
Yes
No
Open mouth breathing consistently?
Yes
No
Comments on your pet's breathing or panting?
Ever fainted/passed out?
Yes
No
Comments on fainting/passing out
Comments on your pet's food consumption
Best phone number to for additional questions:
Please enter a valid phone number.
Submit
Should be Empty: