Questionnaire to Evaluate Behaviors of Old Dogs

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Client Name*







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This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 10 years for smaller ones) so that we can assess changes associated with aging. If your dog is not elderly or you have no complaints that could be associated with age, you do not have to complete this form. If you are uncertain, please complete the form.
1. Locomotory/ambulatory assessment (select only one)








2. Appetite assessment (may select more than one)









3. Assessment of elimination frequency and “accidents” (select only one)






4. Assessment of Bladder Control (select only one)








5. Assessment of Bowel Control (select appropriate answer if this occurs)
Defecates when asleep



Defecates without apparent awareness



Defecates when awake but undesirable or inappropriate areas



No changes in bowel control

6. Visual acuity-how well do you think the dog sees? (select only one)






7. Auditory acuity-how well do you think the dog hears? (select only one)




8. Play interactions-if the dog plays with toys (other pets are addressed later), which situation best describes that play? (select only one)







9. Interactions with humans-which situation best describes that interaction? (select only one)





10. Interactions with other pets- which situation best describes that interaction? (select only one)






11. Changes in sleep/wake cycle (select only one)