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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