AMC Chicago - Senior Wellness Questionnaire

1

Please answer the following questions to help us provide the best care for your senior pet and then, press send.

2

Your Name

Email

3

Pet's Name

4

Date

5

Have you noticed any changes in your pet’s appetite?

Yes

No

6

Has your pet gained or lost weight?

Yes

No

7

Has your pet’s water intake changed?

Yes

No

8

Have you noticed a change in your pet’s energy level?

Yes

No

9

Have you noticed your pet having difficulties walking, jumping or climbing stairs?

Yes

No

10

Does your pet appear to be in pain?

Yes

No

11

Does your pet seem lethargic?

Yes

No

12

Have you noticed your pet urinating more frequently?

Yes

No

13

Does your pet have any urine leakage?

Yes

No

14

Does your pet strain to urinate or defecate?

Yes

No

15

Does your pet have bad breath?

Yes

No

16

Does your pet have any difficulties chewing or playing with toys?

Yes

No

17

Does your pet have soft, loose or very firm stools?

Yes

No

18

Does your pet vomit regularly?

Yes

No

19

Does your pet cough or sneeze?

Yes

No

20

Does your pet have any eye or nose discharge?

Yes

No

21

Does your pet scratch its ears or shake its head?

Yes

No

22

Does your pet itch more than usual?

Yes

No

23

Does your pet seem disoriented?

Yes

No

24

Have you noticed any changes to your pet’s coat?

Yes

No

25

Does your pet have any lumps/bumps you would like us to evaluate?

Yes

No

26

Does your pet still want to participate in your family’s activities?

Yes

No

27

Does your pet still greet you when you come home?

Yes

No

28

Please list the food, treats, supplements or medications you regularly give your pet

29

Would you like to have this performed today?In addition to your pet’s twice yearly physical examination, we recommend a Senior Wellness Laboratory Profile for your pet. The Senior Wellness Profile includes a CBC to evaluate your pet’s red and white blood cell count, a chemistry profile to evaluate your pet’s liver, kidneys and other metabolic functions and a urinalysis.

Yes

No

30

Would you like more information about this comprehensive evaluation?For a more extensive Senior Wellness examination, we recommend the following: CBC, Chemistry, Thyroid Profile, Urinalysis, Chest and Abdominal Radiographs and ECG. We recommend that you schedule in advance a drop off appointment for your pet to be evaluated and an afternoon consultation appointment with your doctor to review our findings.

Yes

No

31

Thank you for completing this questionnaire and for entrusting us with your pet’s care. Your answers will be very helpful in guiding us in our assessment of your pet’s general well being.