Date of Visit:

Appointment Time:

Your Name:

Your Pet's Name:

Your Pet's Breed/Sex:

Your Pet's Birthdate:

Please list any medications that your pet is currently taking (including flea and heartworm preventative):

Describe your pet's diet. Please include the brand name, any treats/table scraps, amount of food given, and how frequently your pet is fed.

Please list any other comments/questions that you may have.

Wanders amilessly: (yes or no)

Appears lost or confused: (yes or no)

Gets "stuck" in corners, or behind furniture: (yes or no)

Stares into space or at walls: (yes or no)

Tremors or shakes: (yes or no)

Difficulty finding the door: (yes or no)

No longer responds to verbal cues or name: (yes or no)

Appears to forget reason to go outside: (yes or no)

Solicits attention less: (yes or no)

Less likely to stand/lie for petting (walks away): (yes or no)

Less enthusiasm upon greeting: (yes or no)

No longer greets owners: (yes or no)

Urinates/defecates indoors in view of owner: (yes or no)

Sleeps more (overall) in 24 hours: (yes or no)

Sleeps less during the night: (yes or no)

Decrease in purposeful activity: (yes or no)

Difficulty climbing stairs: (yes or no)

Difficulty jumping up: (yes or no)

Increased stiffness or limping: (yes or no)

Excessive barking: (yes or no)

Slow to get up after sleeping/lying down: (yes or no)

Urinates indoors: (yes or no, if yes please list number of incidents per week)

Defecates indoors: (yes or no, if yes please list number of incidents per wee)

Signals less to go outside: (yes or no)

Increased thirst: (yes or no)

Increased urination: (yes or no)

Increased frequency of bowel movements: (yes or no)

Change in appetite: (yes or no)

Vomiting/diarrhea: (yes or no)

Coughing: (yes or no)

Trouble seeing: (yes or no)

Loss of hearing: (yes or no)

Bad breath: (yes or no)

Excessive panting: (yes or no)

Skin and/or haircoat changes: (yes or no)

Weight change: (yes or no)

Additional comments: