Senior Health Evaluation Pre-appointment Form

Your Full Name *

Phone Number *

Last Name on File (if different from above)

Pet's Name *

Nutrition

What diet is your pet being fed (brand, type, flavour)? *

How long have they been on this food? *

If you have changed diets in the last year, why did you do so? *

How much of this food are they eating per day (in cups or grams)? *

Please list any other supplemental feeding your pet receives (treats, human food, bones, rawhide or edible dental chews) *

Gastrointestinal

Please list how often your pet vomits *

Please list how often your pet’s appetite is reduced *

Please list how often your pet has diarrhea or soft stool *

Is your pet experiencing any increased urgency to defecate or having bowel movements in the house? *

Mobility

Does your pet seem stiff in the morning or after resting for longer than 30 minutes? If so, how long before this stiffness goes away? *

Is your pet reluctant to use the stairs? *

Is your pet reluctant to jump up on couches or beds if they have previously done so? *

Cats: does your cat still use scratching posts and climb their tree? *

Cats: Does your cat still jump on tables or counters without assistance if they have previously done so? *

Is your pet still able to groom themselves as they did when they were younger? If not, please list how their grooming behaviours have changed. *

Please describe your pet’s exercise routine: *

Behaviour

In addition to the questions in this section please also fill out part 2 of the questionnaire by clicking here. Please email the completed form to info@gatewaypethospital.com.

Please describe your pet’s mental enrichment opportunities: *

Please describe your pet’s sleeping habits (increased, decreased, inconsistent?) *

Is your pet sensitive to any parts of their body being touched (ie face, paws) and has this gotten better or worse as your pet ages? *

Urinary

How often does your pet urinate per day? *

Has the volume or urine changed as your pet ages? Please describe: *

Are they experiencing urinary accidents in the house? *

Skin

Have you noticed any changes to your pet’s skin and coat quality? Please describe: *

Please rate your pet’s itchiness on a scale of 1-10, with 1 being very rare scratching or licking behaviour and 10 being almost non-stop licking or scratching (will stop eating, playing, or wake up at night to lick/scratch) *

Oral Health

Have you noticed any changes to your pet’s breath? If so, please describe: *

Have you noticed any changes to your pet’s eating habits (for example tilting their head to eat on one side, no longer chewing kibble but instead swallowing them whole)? *

Have you noticed your pet pawing at their mouth or increased air licking? *

Respiratory

Have you noticed any changes to your pet’s exercise tolerance such as becoming short of breath with a less intense level of activity? *

Have you noticed any coughing or sneezing? If so, please describe to the best of your ability. Videos of these events are very helpful if these can be brought to the appointment. *

Has the sound of your pet’s breathing or panting changed? *

Eyesight

Have you noticed changes to your pet’s ability to see during the daytime? *

Have you noticed changes to your pet’s ability to see at nighttime? *

Have you noticed an increase of your pet tripping or stumbling? *

Have you noticed a change in your pet’s ability to use the stairs? *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *