Senior Wellness Checklist – Canine Pet* Date* MM slash DD slash YYYY Name* First Last Email* Behavior/Neurologic My dog is just not acting like himself/herself. My dog is not seeking as much attention and interacts less with the family. My dog seems confused or disoriented. My dog has been barking or howling excessively for no apparent reason. My dog's sleeping patterns have changed. My dog has had tremors or episodes of shaking. My dog has displayed circling, head tilts, or repetitive movements. Comments on BehaviorBody Functions My dog has bad breath and red or swollen gums. My dog has difficulty chewing. My dog's eating habits have changed. My dog has gained weight. My dog has lost weight. I'm filling my dog's water bowl more often. (Drinking more) My dog is needing to go outside more often. (Urinating more) My dog's house-training habits have changed and he/she sometimes has accidents. My dog's bowel habits have changed. My dog's bowel habits have increased in frequency. My dog has diarrhea. My dog is constipated. My dog is straining. My dog vomits. My dog seems to have trouble seeing or hearing. Comments on Body FunctionsHeart/Lungs My dog has been coughing, or seems winded after walking or playing. My dog seems to be panting more. My dog tires more rapidly or seems short of breath. Comments on Heart/LungsActivity/Orthopedics I have noticed a change in my dog's behavior or activity level. My dog lags behind on walks. My dog has difficulty climbing stairs and jumping. My dog limps, especially after exercise. My dog shows signs of pain. Comments on ActivitySkin and Coat My dog scratches, licks, and chews excessively. My dog has changes in hair coat, skin, or new lumps or bumps. My dog's skin has an odor. Comments on Skin and CoatWhat foods and treats are you currently feeding your dog? How often? What medications and/or supplements are you currently giving your dog? How often? Medication/Supplements Labels Photo UploadPlease upload a photo of the labels or the bottle of medication and any supplements that you are currently giving your dog. Please group products together in one or two photos. Maximum file upload is 10MB. Drop files here or Select files Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 5. Do you have any specific questions or comments about your dog?CAPTCHA Δ
