Canine Senior Wellness Questionnaire "Friends for Life" Canine Senior Wellness Questionnaire Please complete this form prior to your pets senior wellness visit. This form can help the veterinarian better tailor the visit to your specific pet. Once you have answered everything press the submit button at the bottom. Pet Owner Name* First Last Pet Name* First EmailPlease enter your email in case we have any questions. 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?CAPTCHAEmailThis field is for validation purposes and should be left unchanged.