Client Name*

First

Last

Pet's Name*

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)

No alterations or debilities noted
Modest slowness associated with change from youth to adult
Moderate slowness associated with geriatric aging
Moderate slowness associated with geriatric aging plus alteration or debility in gait
Moderate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs)
Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried)
Severe slowness, extreme loss of function, and decreased willingness or interest in locomoting (spends most of time in bed)
Paralyzed or refuses to move

2. Appetite assessment (may select more than one)

No alterations in appetite
Change in ability to physically handle food
Change in ability to retain food (vomits or regurgitates)
Change in ability to find food
Change in interest in food (may have to do with their ability to smell)
Change in rate of eating
Change in completion of eating
Change in timing of eating
Change in preferred textures

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

No change in frequency and no “accidents”
Increased frequency, no “accidents”
Decreased frequency, no “accidents”
Increased frequency with “accidents”
Decreased frequency with “accidents”
No change in frequency, but “accidents”

4. Assessment of Bladder Control (select only one)

Leaks urine when asleep, only
Leaks urine when awake, only
Leaks urine when awake or asleep
Full-stream, uncontrolled urination when asleep, only
Full-stream, uncontrolled urination when awake, only
Full-stream, uncontrolled urination when awake or asleep
No leakage or uncontrolled urination, all urination controlled, but in inappropriate or undesirable location
No change in urination control or behavior

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

Defecates when asleep

Formed Stool
Diarrhea
Mixed

Defecates without apparent awareness

Formed Stool
Diarrhea
Mixed

Defecates when awake but undesirable or inappropriate areas

Formed Stool
Diarrhea
Mixed

No changes in bowel control

No changes in bowel control

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

No change in visual acuity detected – appears to see as well as ever
Some change in acuity not dependent on ambient light conditions
Some change in acuity dependent on ambient light conditions
Extreme change in acuity not dependent on ambient light conditions
Extreme change in acuity dependent on ambient light conditions
Blind

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

No apparent change in auditory acuity
Some decrement in hearing-not responding to sounds to which the dog used to respond
Extreme decrement in hearing-have to make sure the dog is paying attention or repeat signals or go get the dog when called
Deaf-no response to sounds of any kind

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

No change in play with toys
Slightly decreased interest in toys, only
Slightly decreased ability to play with toys, only
Slightly decreased interest and ability to play with toys
Extreme decreased interest in toys, only
Extreme decreased ability to play with toys, only
Extreme decreased interest and ability to play with toys

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

No change in interaction with people
Recognizes people but slightly decreased frequency of interaction
Recognizes people but greatly decreased frequency of interaction
Withdrawal but recognizes people
Does not recognize people

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

No change in interaction with other pets
Recognizes other pets but slightly decreased frequency of interaction
Recognizes other pets but greatly decreased frequency of interaction
Withdrawal but recognizes other pets
Does not recognize other pets
No other pets or animal companions in house or social environment

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

No changes in sleep patterns
Sleeps more in day, only
Some change-awakens at night and sleeps more in day
Much change-profoundly erratic nocturnal pattern and irregular daytime pattern
Sleeps virtually all day, awake occasionally at night
Sleeps almost around the clock

12. Is there anything else you think we should know?

Questionnaire to Evaluate Behaviors of Old Dogs

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(215) 721-6989

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