Preventive Care Survey for Senior & Geriatric Dogs (6yrs and over)
Dog’s Name
*
Your Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Is your dog microchipped?
Yes
No
Unsure
Please tell us about your dog’s diet.
*
Please tell us about any treats, dental chews, and human food your dog receives.
*
If your dog’s appetite has changed or if his/her eating habits have changed, please describe here.
Does your dog readily eat his/her food? If not, do you offer treats/human food to entice your dog to eat? Please describe here.
*
Does your dog have difficulty chewing or swallowing? Please describe here.
Has your dog had any weight fluctuations?
Yes
No
Has it become a challenge to maintain your dog’s weight?
Yes
No
Does your dog tolerate exercise and play like before?
*
Yes
No
Does your dog seem to be slow or painful when rising?
*
Yes
No
Does your dog seem more sensitive to your grooming or touching over the lower back/hips?
*
Yes
No
Does your dog wander aimlessly and/or seem disoriented?
*
Yes
No
Does your dog seem increasingly anxious, fearful, or irritable?
*
Yes
No
Has your dog exhibited any unusual vocalizations?
*
Yes
No
Does your dog seem to act “old”?
*
Yes
No
Does your dog seem to enjoy life as much as before?
*
Yes
No
If your dog has had any behavior changes since his/her last visit, please describe here.
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Submit
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