Although you rely on us to be the “experts”, you are the one who cares for your pet – day in and day out – and, therefore, you are more likely to notice subtle changes in your pet’s behavior or physical abilities. Help us make the most of your “Golden Paws” Senior Care visit and take a few moments to complete this checklist. What may look like normal signs of aging could actually be early signs of a manageable health condition.

Appointment date:

Your name:

Email:

Your pet's name:

Your pet's breed:

Your pet's sex:
---MaleFemale

Your pet's birthdate:

List any medications that your pet is currently taking (including flea and heartworm preventative).

Describe your pet’s diet. Please include the brand name, any treats/table scraps, amount of food given, and how frequently your pet is fed.

Please list any other comments/questions that you may have.

Disorientation

Please check any that apply:
Wanders aimlesslyAppears lost or confusedGets stuck in corners or behind furnitureStares into space or at wallsTremors or shakesDifficulty finding the doorNo longer responds to verbal cues or nameAppears to forget reason to go outside

Please add information for your choices above:

Interaction with family

Please check any that apply:
Solicits attention lessLess likely to stand/lie for petting (walks away)Less enthusiasm upon greetingNo longer greets ownersUrinates/defecates indoors in view of owner

Please add information for your choices above:

Sleep and activity

Please check any that apply:
Sleeps more (overall) in 24 hoursSleeps less during the nightDecrease in purposeful activityDifficulty climbing stairsDifficulty jumping upIncreased stiffness or limpingExcessive barkingSlow to get up after sleeping/lying down

Please add information for your choices above:

House training

Please check any that apply:
Urinates indoors (#incidents per week)Defecates indoors (#incidents per week)Urinates/defecates indoors in view of ownerSignals less to go outside

Please add information for your choices above:

Physical changes

Increased thirstIncreased urinationIncreased frequency of bowel movementsChange in appetiteVomiting/diarrheaCoughingTrouble seeingLoss of hearingBad breathExcessive pantingSkin and/or haircoat changesWeight change

Please add information for your choices above:

Additional comments: