Preventive Care Survey for Senior & Geriatric Dogs (6yrs and over)
Dog’s Name
*
Your Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is your dog microchipped?
Yes
No
Unsure
Please tell us about your dog’s diet.
*
Please tell us about any treats, dental chews, and human food your dog receives.
*
If your dog’s appetite has changed or if his/her eating habits have changed, please describe here.
Does your dog readily eat his/her food? If not, do you offer treats/human food to entice your dog to eat? Please describe here.
*
Does your dog have difficulty chewing or swallowing? Please describe here.
Has your dog had any weight fluctuations?
Yes
No
Has it become a challenge to maintain your dog’s weight?
Yes
No
Does your dog tolerate exercise and play like before?
*
Yes
No
Does your dog seem to be slow or painful when rising?
*
Yes
No
Does your dog seem more sensitive to your grooming or touching over the lower back/hips?
*
Yes
No
Does your dog wander aimlessly and/or seem disoriented?
*
Yes
No
Does your dog seem increasingly anxious, fearful, or irritable?
*
Yes
No
Has your dog exhibited any unusual vocalizations?
*
Yes
No
Does your dog seem to act “old”?
*
Yes
No
Does your dog seem to enjoy life as much as before?
*
Yes
No
If your dog has had any behavior changes since his/her last visit, please describe here.
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Submit
Should be Empty: