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you can just copy and paste this questionnaire into a word document to print it off
Please bring your complete questionnaire, along with a urine sample, to the surgery for the senior Health Check.
N.B. If there are areas about which you are unsure, do not fill those areas in, but wait until you see the nurse at the surgery to explain the problem.
PATIENTS NAME…………………………… AGE…………….
BREED……………………….. DATE…………..
Nutrition What food does your pet eat?............................................................................. Please describe any treats, supplements or table scrapes your pet receives and how often………………………………………………………………………… …………………………………………………………………………………………. How many times does your pet eat………………………………………………… How is your pet’s appetite? Excessive/Good/Fair/Poor Have you observed any changes in your pets eating habits or appetite recently? Yes / No / Unsure Exercise (dogs only) How much and how often do you exercise your dog?........................................ If your dog has any problems with exercise please describe………………….... ………………………………………………………………………………………….. Does your pet tire easily? Yes / No / Unsure Does your pet have trouble breathing or cough during or soon after exercise? Yes / No / Unsure
Weight How do you monitor your pet’s weight? Weigh / Observe only Has your pet’s weight changed recently? Increased / decreased / no change Dental Care Do you ever brush your pet’s teeth? Yes / No Does your pet’s breath smell unpleasant? Yes / No / Unsure Behaviour Have you recently felt that your pet is more: Sensitive to pain? Yes / No / Unsure Lethargic, quiet or dull? Yes / No / Unsure Moody or less tolerant? Yes / No / Unsure Anxious / Nervous? Yes / No / Unsure Have you noticed any other recent changes in your pet’s behaviour? Yes / No / Unsure Is your pet less enthusiastic to go for walks / play with toys? Yes / No / Unsure Does your pet lag behind on walks / have less energy? Yes / No / Unsure Does you pet spend more time sleeping instead of interacting with you? Yes / No / Unsure
Have you noticed any changes in your pet’s vision? Yes / No / Unsure Does your pet run into objects or become anxious in unfamiliar surroundings? Yes / No / Unsure Have you noticed any changes in you pets hearing? Yes / No / Unsure
Is your pet sometimes less responsive to command? Yes / No / Unsure Does you pet sometimes show signs of confusion? Yes / No / Unsure
Other information How much water does your pet drink in a day on average?.........Pints Have there been any recent changes in: The amount of water drunk More / less / no change The frequency of drinking More / less / no change Have there been any changes in your pet’s urine: The frequency More / less / no change / unsure The amount More / less / no change / unsure The colour Yes / No / Unsure The odour Yes / No / Unsure Does your pet have trouble going the whole night without urinating or defecating? Yes / No / Unsure Have there been changes in your pet’s motions? The frequency More / less / no change The amount passed More / less / no change Consistency Looser / Firmer / no change Colour Darker / Lighter / no change Have you noticed your pet limping, stiff or painful in the morning or just after wakening? Yes / No / Unsure If so, does the pain appear to subside after a while? Yes / No / Unsure Are there any changes with your pet’s skin or coat condition? Yes / No / Unsure Does your pet scratch or nibble at their coat excessively? Yes / No / Unsure Please describe any baldness / scurf / redness………………………………… Does your pet cough or sneeze excessively? Yes / No / Unsure Does your pet have a nasal or eye discharge? Yes / No / Unsure Does your pet scratch their ears or shake their head? Yes / No / Unsure Does your pet have any unusual bumps or lumps anywhere? Yes / No / Unsure
If so please describe where……………………………………………………….. Please give details of any special concerns you may have about your pet or its health………………………………………………………………………………
you can just copy and paste this questionnaire into a word document to print it off |
