Geriatric Questionnaire

Geriatric Questionnaire

The effects of the natural aging process can slowly take a toll on companion animals. It can be difficult to notice these changes unless you look for specific clues. Since you know your pet better than anyone, you may be best to notice the subtle changes in your pet’s behavior, habits and activities. This form will provide your veterinarian with the necessary information to help diagnose conditions – many of which can be managed, providing a better quality of life for your pet, even in their advanced age.

PATIENT INFORMATION

Species
Sex

SLEEP PATTERNS

Do they wake up during the night?
If yes, what do they wake up to do?
Select all that apply

HOUSE TRAINING

Has there been…?
Select all that apply

EARS/EYES/NOSE/THROAT

Have you noticed…
Select all that apply
If vision problems…
Mark all that apply

SKIN

Have you noticed…
Select all that apply
Is your pet's skin:
Does your pet seek out areas that are:
(Cats only) Is your pet grooming themselves regularly?

MENTATION

Does your pet do any of the following?
Select all that apply

EATING/DRINKING

Has there been…?
Select all that apply

MOBILITY

Select all of the following that pertain to your pet:
Which floor types are in your home?
Select all that apply
Has your pet's activity level changed in the past year?

MISCELLANEOUS QUESTIONS

List your pet's top 5 favorite things:
List 3 things your pet hates:
Please enter a number from 1 to 10.