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. Enter Email Confirm Email Please select the location of your pet's senior wellness appointment.*Please selectRochesterDoverMiltonNot Sure / Scheduled YetBehavior / 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 meowing or howling whimpering 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. Litter-box habits have changed and 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 the heart or lung capacity? Please check all that apply. If none, select none observed. Has been coughing or sneezing. Seems to be panting more. Tires quickly or seems short of breath. None observed. Activity / Orthopedics*Have you noticed any changes in activity or orthopedics? Please check all that apply. If none, select none observed. Change in behavior or activity level. Difficulty climbing stairs and jumping. Seems limp or stiff and has difficulty rising from a resting position. Shows signs of pain: hiding, unusally quiet, or vocalizing. None observed. Skin and Coat*Have you noticed any changes in the 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. Grooming habits have changed. None observed. Do you have any specific questions or concerns about your senior cat?CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.