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Home New Clients Online Forms Questionnaire to Evaluate Behaviors of Old Dogs

Questionnaire to Evaluate Behaviors of Old Dogs

"*" indicates required fields

Client Name*

First

Last

Pet's Name*

Phone*

Email*

Home Address*

Street Address

City

State / Province / Region

ZIP / Postal Code

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

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?

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(215) 721-6989

78 Souderton Hatfield Pike
Souderton, PA 18964

Make an Appointment

Online Pharmacy

78 Souderton Hatfield Pike
Souderton, PA 18964

HOME
ABOUT
CLIENT FORMS
SERVICES
URGENT CARE
ONLINE PHARMACY
FEAR FREE
CONTACT
- Send Us A Message
- PetDesk Mobile App

Make an Appointment

(215) 721-6989

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