SENIOR HEALTH CHECK LIST

Your Name      Your Pet's Name      Date

Pet's Age   Pet's Weight     Pet's Breed       Dog   Cat    Other

Diet      How Much & How Often Do You Feed Your Pet?

Environment  Indoors    Outdoors           Family/Pet Members

EXERCISE:

Kind    Frequency     None   Mild   Mod Severe Began When?

WEIGHT GAIN:

 Gain    Loss     None   Mild   Mod Severe Began When?

APPETITE:

Increase    Decrease     None   Mild   Mod Severe Began When?

VOMITING:

Food    Fluid Color     None   Mild   Mod Severe Began When?

DIARRHEA:

Frequency    Consistency     None   Mild   Mod Severe Began When?

CONSTIPATION:   Difficult Defecation      None   Mild   Mod Severe Began When?

DRINKING:

Increase    Decrease     None   Mild   Mod Severe Began When?

URINATION:

Increased Volume Color    Frequency   None   Mild   Mod Severe Began ?

HOUSE SOILING:

Inappropriate Urination         None   Mild   Mod Severe Began ?

Incontinence         None   Mild   Mod Severe Began ?

Bowel Movements         None   Mild   Mod Severe Began ?

RESPIRATORY SYSTEM:

Coughing         None   Mild   Mod Severe Began ?

Weakness After Exercise         None   Mild   Mod Severe Began ?

Increased Panting         None   Mild   Mod Severe Began ?

Labored Breathing         None   Mild   Mod Severe Began ?

SKIN PROBLEMS:

Lumps or Tumors         None   Mild   Mod Severe Began ?

Haircoat Changes         None   Mild   Mod Severe Began ?

Hair Loss         None   Mild   Mod Severe Began ?

TEETH:

Bad Breath         None   Mild   Mod Severe Began ?

Sore Gums         None   Mild   Mod Severe Began ?

Difficult Chewing         None   Mild   Mod Severe Began ?

MUSCLES:

Muscle Tremors         None   Mild   Mod Severe Began ?

Shaking         None   Mild   Mod Severe Began ?

Weakness         None   Mild   Mod Severe Began ?

Increased Stiffness         None   Mild   Mod Severe Began ?

Difficulty Climbing Stairs         None   Mild   Mod Severe Began ?

Difficulty Jumping Up         None   Mild   Mod Severe Began ?

Uncoordinated         None   Mild   Mod Severe Began ?

INTERACTION WITH OTHERS:

Decreased affection/interaction with owners         None   Mild   Mod Severe Began ?

Decreased Recognition of people/animals         None   Mild   Mod Severe Began ?

Forgets previously learned commands         None   Mild   Mod Severe Began ?

HEARING & VISION:

Decreased hearing or selective hearing         None   Mild   Mod Severe Began ?

Vision Loss         None   Mild   Mod Severe Began ?

Low light only         None   Mild   Mod Severe Began ?

PERSONALITY:

Increased Fear         None   Mild   Mod Severe Began ?

Increased Anxiety         None   Mild   Mod Severe Began ?

Increased Irritability         None   Mild   Mod Severe Began ?

Increased Aggression         None   Mild   Mod Severe Began ?

Decreased tolerance of handling         None   Mild   Mod Severe Began ?

Decreased tolerance of being left alone         None   Mild   Mod Severe Began ?

Decreased tolerance of awareness         None   Mild   Mod Severe Began ?

Gets Lost         None   Mild   Mod Severe Began ?

Gets Confused         None   Mild   Mod Severe Began ?

Gets Disoriented         None   Mild   Mod Severe Began ?

REPETITIVE and/or COMPULSIVE BEHAVIOR:

Self Injury         None   Mild   Mod Severe Began ?

Pacing         None   Mild   Mod Severe Began ?

Circling         None   Mild   Mod Severe Began ?

Licking Non-Food Items         None   Mild   Mod Severe Other       Began ?

ACTIVITY:

Excessive Vocalization or Barking         None   Mild   Mod Severe Began ?

Decreased Activity      Sleeps More      None   Mild   Mod Severe Began ?

Changes in sleeping pattern         None   Mild   Mod Severe Began ?

PLEASE TELL US ABOUT ANY OTHER PROBLEMS NOT NOTED ABOVE

MEDICATIONS CURRENTLY TAKING

The doctor/technician will review this checklist with you.