NVAC Senior Health Check List

Your Name

Your Pet's Name

Date

Pet's Age

Pet's Weight

Pet's Breed

Dog

Cat

Other

Diet

How Much & How Often Do You Feed Your Pet?

Environment

Indoors

Outdoors

Family/Pet Members

EXERCISE:

None

Mild

Mod

Severe

Kind

Frequency

Began When?

VOMITING:

None

Mild

Mod

Severe

Food

Fluid Color

Began When?

DIARRHEA:

None

Mild

Mod

Severe

Frequency

Consistency

Began When?

CONSTIPATION:

None

Mild

Mod

Severe

Difficult Defecation Began When?

Began When?

Color?

Frequency?

Began When?

HOUSE SOILING:

Inappropriate Urination

None

Mild

Mod

Severe

Incontinence

None

Mild

Mod

Severe

Bowel Movements

None

Mild

Mod

Severe

Began When?

RESPIRATORY SYSTEM:

Coughing

None

Mild

Mod

Severe

Weakness After Exercise

None

Mild

Mod

Severe

Increased Panting

None

Mild

Mod

Severe

Labored Breathing

None

Mild

Mod

Severe

Began When?

SKIN PROBLEMS:

Lumps or Tumors

None

Mild

Mod

Severe

Haircoat Changes

None

Mild

Mod

Severe

Hair Loss

None

Mild

Mod

Severe

Began When?

TEETH:

Bad Breath

None

Mild

Mod

Severe

Sore Gums

None

Mild

Mod

Severe

Difficult Chewing

None

Mild

Mod

Severe

Began When?

MUSCLES:

Muscle Tremors

None

Mild

Mod

Severe

Shaking

None

Mild

Mod

Severe

Weakness

None

Mild

Mod

Severe

Increased Stiffness

None

Mild

Mod

Severe

Difficulty Climbing Stairs

None

Mild

Mod

Severe

Difficulty Jumping Up

None

Mild

Mod

Severe

Uncoordinated

None

Mild

Mod

Severe

Began When?

INTERACTION WITH OTHERS:

Decreased affection/interaction with owners

None

Mild

Mod

Severe

Decreased Recognition of people/animals

None

Mild

Mod

Severe

Forgets previously learned commands

None

Mild

Mod

Severe

Began When?

HEARING AND VISION:

Decreased hearing or selective hearing

None

Mild

Mod

Severe

Vision Loss

None

Mild

Mod

Severe

Low light only

None

Mild

Mod

Severe

Began When?

PERSONALITY:

Increased Fear

None

Mild

Mod

Severe

Increased Anxiety

None

Mild

Mod

Severe

Increased Irritabilty

None

Mild

Mod

Severe

Increased Aggression

None

Mild

Mod

Severe

Decreased tolerance of handling

None

Mild

Mod

Severe

Decreased tolerance of being left alone

None

Mild

Mod

Severe

Decreased awareness

None

Mild

Mod

Severe

Gets Lost

None

Mild

Mod

Severe

Gets Confused

None

Mild

Mod

Severe

Gets Disoriented

None

Mild

Mod

Severe

Began When?

REPETITIVE and/or COMPULSIVE BEHAVIOR:

Self Injury

None

Mild

Mod

Severe

Pacing

None

Mild

Mod

Severe

Circling

None

Mild

Mod

Severe

Licking Non-Food Items

None

Mild

Mod

Severe

Began When?

ACTIVITY:

Excessive Vocalization or Barking

None

Mild

Mod

Severe

Decreased Activity

None

Mild

Mod

Severe

Changes in sleeping pattern

None

Mild

Mod

Severe

Began When?

PLEASE TELL US ABOUT ANY OTHER PROBLEMS NOT NOTED ABOVE

MEDICATION CURRENTLY TAKING

The doctor/technician will review this checklist with you.

* Indicates Response Required


Powered by FormSite.com

Increase	Decrease	None
Mild	Moderate	Severe

Increase	Decrease	None
Mild	Moderate	Severe