Senior Pet Questionnaire

Which practice would you like to register with?

Select a surgery

Contact details

Your Full Name*

Email*

Contact Number

Pet details

Patients' Names

Your pet's species*

Pet Breed

Your pet's sex

Date of Birth

Is your pet neutered?

Appearance and Body Condition

Do you think your pet’s body weight has changed

IncreasedSameDecreased

Have you noticed any of the following regarding your pet’s coat/skin? (tick all those that apply)

Dullness
Loss of hair
Matting
Oily
Dandruff
Itchiness
No changes

Is your pet still able to groom themself?

YesNO

Have you noticed any lumps or bumps on your pet?

YesNo

If YES, please give details

Have you noticed any of the following? (tick all those that apply)

Wheezing
Excercise intolerance
Coughing
Shortness of breath
Mouth breathing
No changes

Do you have any concerns regarding your pet’s vision or hearing?

YesNo

If YES, please give details

Eating and Drinking

Has your pet's appetite

IncreasedSameDecreased

Does your pet have any problems eating?

YesNo

Please tell us the diet that your pet is on including quantities and any treats given

Have you noticed that your pet suffers with any of the following, regularly? (tick all those that apply)

ConstipationDiarrhoeaHairballsVomitingNone of the above

Has your pet's thirst

Increased
Reamined the same
Decreased

Sleep

How many hours sleep does your pet average a day?

Does your pet now sleep more during the day and sleep less at night?

YesNo

Do they have a peaceful sleep at night?

YesNo

If NO, do they get up during the night to (tick all those that apply)

UrinateDefecateDrink WaterPantPaceWhineBarkOther

Mobility

Does have any of these mobility issues?

Trouble with stairs
Pain
Spends a lot more time lying down
Stifness
Lameness
Requires assistance to get up
Has difficulty jumping (ie into the car (dogs), up fences (cats)
None of the above

What floor type(s) do you have at home? (tick all those that apply)

TileWoodCarpetLaminateRugs

What is your pet’s exercise schedule? (eg. Length of walk and frequency)

Has this changed in the past year?

YesNo

If YES, why?

Behaviour & Additional Info

Have you noticed your pet doing any of the following? (tick all those that apply)

Staring off into space
Pacing, circling or seeming restless
Acting disorientated, lost or distant
Being more grumpy and/or aggressive
Yowling (cats)/Barking (dogs) for no reason
Being less keen to play or less interested in interaction and attention
Having accidents and toileting indoors, when previously they were house trained?
None of the above

Is your pet on any medication or supplements

Yes
No

If YES, please give details

Please tell us of any other concerns you may have regarding your pet

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Senior Pet Questionnaire

Which practice would you like to register with?

Contact details

Pet details

Appearance and Body Condition

Eating and Drinking

Sleep

Mobility

Behaviour & Additional Info

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