Senior Checkup Form – Canine"*" indicates required fieldsDate* MM slash DD slash YYYY Patient's Name* Patient's Name Circle the appropriate response:* Male Female Male Neutered Female SpayedBreed*Color*Date of Birth or Approx. Age*Owner's Name* First Last Owner's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneCell Phone*Email NUTRITION/DIET INFORMATIONWhat brand does your pet eat? Dry, canned or moist?Please describe any snacks, supplements, or table food your pet receives & how often.Who feeds the pet?How many times a day does your pet eat?How is your pet’s appetite?Have you noticed any changes in your pets eating habits or appetite recently?EnvironmentDoes your pet live indoors, outdoors, or both?If outdoors or both, where does your pet sleep?Are there other pets in the family? If so, how many & what kind(s)?Are there any young children in the family?Does your pet seek warm places to lie down (heat vent, fireplace, etc?)EXERCISEWhat kind of exercise or playtime does your pet get and how often?Please describe any problems with this exercise. Does your pet have trouble jumping?Does your pet tire easily?WEIGHTHow do you monitor your pet’s weight? (Scale, visually, other?)Have you noticed any recent weight loss or gain?DENTAL CAREHas your pet ever had its teeth cleaned? If so, when was the last time? How often does your pet have professional cleanings?Do you ever brush your pet’s teeth?Does your pet ever seem to have trouble chewing?BEHAVIORHave you noticed any changes in your pet’s behavior? If so, please describe.Please list any behavioral problemsHave you recently felt your pet was (please check all appropriate answers):* More sensitive to pain More lethargic Moody Less Tolerant More anxious/nervous More likely to disobey commands No changeWhen did you notice changes?SPECIAL SENSESHave you noticed any changes in your pet’s vision?Does your pet run into objects or become anxious in an unfamiliar environment?Have you noticed any changes in your pet’s hearing?Is your pet sometimes less responsive to commands?OTHER INFORMATIONHow much water does your pet drink in a day?Any recent changes in amount of water or frequency of drinking?Any changes in amount or frequency of urination?Does your pet ever dribble or leak urine?Does your pet have trouble getting through the whole night without urinating or defecating?Any changes in amount or frequency of your pet’s bowel movements?Have you noticed any limping, stiffness, or pain when your pet first gets up? Does he/she improve after awhile?Any problems with skin or hair coat?Any lumps or bumps?Any past medical problems of which we are not aware?What medications/supplements are your pet taking currently?CommentsThis field is for validation purposes and should be left unchanged.
