Preventive Care Survey For Senior or Geriatric Dogs (6 yrs or over)

Preventive Care Survey For Senior or Geriatric Dogs (6 yrs or over)

Please provide your details below and we will get back to you shortly.

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Dog’s Name *

Your Name *

First

Last

it microchipped? human

Email *

Phone Number *

Is your puppy 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 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.

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