Senior Wellness Questionnaire

Name
Phone Number
Pet's name
Signs
Change in water consumption   yes    no
Change in amount of urine production   yes    no
Unable to hold urine all night or wet spots where he/she sleeps   yes    no
Appetite increased   yes    no
Appetite decreased   yes    no
Vomiting or regurgitating food after eating   yes    no
Diarrhea   yes    no

Constipation or straining to defecate

   yes    no
Weight gain   yes    no
Weight loss   yes    no
Bad breath or drooling   yes    no
Coughing?
If so, when is it the worst?
Excessive panting and/or breathing heavily at rest   yes    no
Tires easily at exercise   yes    no
Increased stiffness, trouble jumping or walking   yes    no
Limping? Duration? Which Leg (s)?
Does your dog go outside on walks, dog parks, groomers   yes    no
Does your cat go outside routinely   yes    no
New lumps and bumps? where?
Hair coat thinner or slow to re-grow after clip or shed?   yes    no
Noticeable decrease in vision?   yes    no
Noticeable decrease in hearing?   yes    no
Other health concerns

Diet
What food (s) do you feed? how much? canned? dry?
What treats do you give routinely
Do you give your pet any other supplements or vitamins? which ones?
We will check your pets records for current medications and past medical problems. If your pet is a new patient, please provide us a brief recent medical history and a list of medications and dose.
Thanks ! please submit your request, and we will contact you soon

 
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Links


Baring Boulevard Veterinary Hospital
700 Baring Blvd.   Sparks, NV 89434
ph 775-358-6880    fax 775-358-9115
baringvet@gmail.com

website comments or suggestions.. rgsdvm@baringvet.net