Canine Senior Wellness Questionnaire in Dover, NH | Broadview Animal Hospital of Dover

Pet Owner Name*
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Pet Name*
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Email
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Behavior / Neurologic*
Have you noticed any behavioral or neurological changes? Please check all that apply. If none, select none observed.
- Just not acting like himself / herself.
- Interacts less with the family.
- Seems confused or disoriented.
- Been barking or howling excessively for no reason.
- Sleeping patterns have changed.
- Has had tremors or espidodes of shaking.
- Has displayed circling, head tilts, or repetitive movements.
- None observed
Body Functions*
Have you noticed any changes in body functions? Please check all that apply. If none, select none observed.
- Has bad breath and / or red or swollen gums.
- Has difficulty chewing.
- Eating habits have changed
- Gained weight.
- Lost weight.
- Drinking more water than usual.
- Urinating more frequently than usual.
- House training habits have changed, sometimes has accidents.
- Bowel movements have changed (more often, diarrhea, constipation, straining).
- Vomits more than occasionally.
- Seems to have trouble seeing or hearing.
- None observed.
Heart / Lungs*
Have you noticed any changes in heart or lung capacity? Please check all that apply. If none, select none observed.
- Has been coughing after walking or playing.
- Seems to be panting more.
- Tires quickly or seems short of breath.
- None observed.
Activity / Orthopedics*
Have you noticed any changes in activity level or orthopedics? Please check all that apply. If none, select none observed.
- Change in behavior or activity level.
- Lags behind on walks.
- Difficulty climbing staris and jumping.
- Limps, especially after exercise.
- Shows signs of pain.
- None observed.
Skin and Coat*
Have you noticed any changes in skin or coat? Please check all that apply. If none, select none observed.
- Scratches, licks, and / or chews excessively.
- Has changes in hair coat, skin, or new lumps or bumps.
- Skin has an odor.
- None observed.
Do you have any specific questions or concerns about your senior dog?
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