SENIOR DOG QUESTIONNAIRE
Patient Name and Last Name: ___Date: ______
SENIOR DOG QUESTIONNAIRE
PERSONALITY: PROBLEMATIC SYMPTOMS:
Tires easily Vomiting
Sleeping more than 13hr/day Diarrhea
Depressed Blood or mucous in the stool
Not greeting you Loose stool
Not playing Continuous discharge in the eyes
Not Wagging Tail Excessive loss of hair or excessive shedding
Not enjoying treats Coughing
Turning aggressive Sneezing
Snappy or grumpy Lumps and bumps
Anxiety Loss of Bladder Control
PAIN AND DISCOMFORT: PHYSICAL CHANGES:
Declining activity level Cloudy or bloodshot eyes
Trouble keeping balance Having vision trouble
Trouble getting up Bumping into things
Restless Disoriented or Confused
Can’t get comfortable Not coming when called
Whining Not responding to noise
Yelping Appetite increase
Stiff legs while walking Appetite decrease
Stiffness getting up on a cold morning Water consumption increase
Tail continuously between legs Water consumption decrease
Shaking continuously Labored breathing
Heavy continuous panting Urinating frequently
Mouth Pain Having accidents in the house
Dull, unkempt hair coat Doesn’t recognize you
COMMENTS: _______________________________________________________________
____________________________________________________________________________
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