Senior Pet Checklist Owners Name* First Last Species*CanineFelinePets Name*Weight gain?YesNoWhen did problem begin?Weight loss?YesNoWhen did problem begin?Appetite increase?YesNoWhen did problem begin?Appetite decrease?YesNoWhen did problem begin?Vomiting?YesNoWhen did problem begin?Diarrhea?YesNoWhen did problem begin?Colitis (stool with mucus or blood) ?YesNoWhen did problem begin?Constipation/difficult defecation?YesNoWhen did problem begin?Increased drinking?YesNoWhen did problem begin?Increased urine?YesNoWhen did problem begin?Coughing?YesNoWhen did problem begin?Weakness after exercise?YesNoWhen did problem begin?Panting?YesNoWhen did problem begin?Lumps/tumors?YesNoWhen did problem begin?Skin problems?YesNoWhen did problem begin?Describe?YesNoWhen did problem begin?Bad breath/sore gums/difficulty chewing?YesNoWhen did problem begin?Muscle tremors/shaking?YesNoWhen did problem begin?Weakness/incoordination?YesNoWhen did problem begin?Difficulty climbing stairs/increased stiffness?YesNoWhen did problem begin?Diminished vision?YesNoWhen did problem begin?Diminished hearing?YesNoWhen did problem begin?Housesoiling Urine horizontal surface Urine vertical surface Bowel movement Urinary incontinence Indoor elimination in view of family Goes outdoors, eliminates indoors on return Elimination in crate or sleeping area When did you first notice the problem(s)?Impaired learning/memory Decreased ability to work Forgets name/commands/previously learned tasks Decreased recognition of familiar people/animals When did you first notice the problem(s)?Social: Decreased interest in petting/affection Decreased tolerance of handling More possessive Increased need or demand for affection/attention Problems with social relationships with other pets When did you first notice the problem(s)?Disorientation Gets lost Confused Goes to wrong side of door Can’t find dropped food Can’t maneuver around obstacles When did you first notice the problem(s)?Anxiety/aggression Decreased tolerance of being left alone Increased irritability Restless/agitated Anxiety Can’t maneuver around obstacles Fearful Phobias Aggression When did you first notice the problem(s)?Purposeless/repetitive activity Vocal (whining, barking) Paces Circles Licks Stares into space Self-trauma Sucking Hallucinates When did you first notice the problem(s)?Sleep – wake cycles Wakes at night/restless sleep Decreased activity during the day/sleeps more When did you first notice the problem(s)?Apathy/depression Less reactive Listless Decreased interest in food Decreased self-grooming When did you first notice the problem(s)?Other problems/concerns (or use this space to describe any of the above in more detail)List medications, diet or supplements your pet is taking:Has your pet been previously diagnosed as having any medical problems? Y/N Describe:
