Senior Pet Questionnaire

Your Full Name *

Phone Number *

Email Address *

Pet's Name *

Tell Us About Your Pet's Health

What is your pet’s current diet (brand/amount/ canned or dry)? *

What treats or human food (what treat/food/amount/frequency) does your pet receive? *

Are there any changes to your pet’s appetite or thirst? *

Has your pet experienced any unexpected weight loss or gain? *

Have there been any changes in your pet’s urination volume or frequency? (ie. normal, increased or decreased) *

Have there been any changes to your pet’s bowel movements (ie. normal, soft, hard)? Does your pet experience difficulty in passing bowel movements? *

Does your pet experience vomiting and if so how frequently? *

Does your pet experience any coughing or sneezing of concern? *

Do you have any concerns about your pet’s skin (ie. redness, itchiness, lumps or bumps)? *

How is your pet’s energy level? *

Does your pet experience any difficulty in rising, sitting, jumping or doing stairs? *

Is your pet experiencing any changes in their hearing or vision? *

Does your pet travel outside of the City of Winnipeg? If so, where? *

Does your pet allow any dental homecare? (ie. tooth brushing, dental treats, dental food, bone, or antlers) *

Is your pet on any medications? If so, please list brand name dose and frequency of administration if not dispensed by Westwood Veterinary Hospital. *

Does your pet receive any over the counter supplements including joint supplements? If so, please list brand and frequency of administration? *

Cat Owners – How often does your cat go outside?

Cat Owners - Does your cat still groom itself as frequently as when it was younger?

Does your pet go to dog parks, groomers boarding facilities or daycares? *

Do you have pet insurance? If yes, please specify the provider. If no, are you interested in a free no obligation 4-week trial of pet insurance or further information about pet insurance? *

Do you have any other concerns or notes for the doctor?

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *