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Stack Vet - Geriatric Screening Questionnaire
1
First Name
Last Name
Pet's Name
Email
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No alterations or debilities noted
Modest slowness associated with change from youth to adult
Moderation 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 (i.e. cannot climb stairs)
Severe slowness, extreme loss of function, and decreased willingness or interest in moving (spends most time in bed)
Paralyzed or refuses to move
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No alterations or debilities noted
Modest slowness associated with change from youth to adult
Moderation 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 (i.e. cannot climb stairs)
Severe slowness, extreme loss of function, and decreased willingness or interest in moving (spends most time in bed)
Paralyzed or refuses to move
Mobility Assessment
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
Change in rate of eating
Change in completion of eating
Change in timing of eating
Change in preferred textures of food
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
Change in rate of eating
Change in completion of eating
Change in timing of eating
Change in preferred textures of food
Appetite Assessment (check all that apply)
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2
Assessment of elimination function (check one in each category)
No change in frequency, no “accidents”
Increased frequency, no “accidents”
Decreased frequency, no “accidents”
Increased frequency with “accidents”
Decreased frequency with “accidents”
No change in frequency, but “accidents”
No change in frequency, no “accidents”
Increased frequency, no “accidents”
Decreased frequency, no “accidents”
Increased frequency with “accidents”
Decreased frequency with “accidents”
No change in frequency, but “accidents”
Changes in frequencies and “accidents”
Leaks urine when asleep
Leaks urine when awake
Leaks urine when awake and asleep
Full-stream, uncontrolled urination when asleep
Full-stream, uncontrolled urination when awake
Full-steam, 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
Leaks urine when asleep
Leaks urine when awake
Leaks urine when awake and asleep
Full-stream, uncontrolled urination when asleep
Full-stream, uncontrolled urination when awake
Full-steam, 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
Bladder Control
Defecates when asleep
Defecates without apparent awareness
Defecates when awake and aware of action, but in inappropriate or undesirable locations
No changes in bowel control
Defecates when asleep
Defecates without apparent awareness
Defecates when awake and aware of action, but in inappropriate or undesirable locations
No changes in bowel control
Bowel Control
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No change in vision detected by behavior, appears to see as well as ever
Some change in vision not dependent on light conditions
Some change in vision dependent on light conditions
Extreme change in vision not dependent on light conditions
Extreme change in vision dependent on light conditions
Blind
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No change in vision detected by behavior, appears to see as well as ever
Some change in vision not dependent on light conditions
Some change in vision dependent on light conditions
Extreme change in vision not dependent on light conditions
Extreme change in vision dependent on light conditions
Blind
Visual Activity: How well do you think your dog or cat sees?
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3
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No apparent change in hearing
Some hearing loss
Extreme hearing loss
Deaf
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No apparent change in hearing
Some hearing loss
Extreme hearing loss
Deaf
Auditory Acuity: How well do you think your dog or cat hears?
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No change in play with toys
Slightly decreased interest in toys
Slightly decreased ability to play with toys
Slightly decreased interest and ability to play with toys
Extreme decreased interest in toys
Extreme decreased ability to play with toys
Extreme decreased interest and ability to play with toys
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No change in play with toys
Slightly decreased interest in toys
Slightly decreased ability to play with toys
Slightly decreased interest and ability to play with toys
Extreme decreased interest in toys
Extreme decreased ability to play with toys
Extreme decreased interest and ability to play with toys
Play interactions: If your dog or cat plays with toys, which situation best describes that play?
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No change in interactions 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
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No change in interactions 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
Interactions with people: Which situation best describes that interactions?
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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
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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
Interactions with other pets: Which situations best describes that interaction?
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No change in sleep patterns
Sleeps more during the day
Some changes, awakens at night and sleeps more during the day
Much change, profoundly erratic nocturnal pattern and irregular daytime pattern
Sleeps virtually all day, awake occasionally at night
Sleeps almost around the clock
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No change in sleep patterns
Sleeps more during the day
Some changes, awakens at night and sleeps more during the day
Much change, profoundly erratic nocturnal pattern and irregular daytime pattern
Sleeps virtually all day, awake occasionally at night
Sleeps almost around the clock
Changes in sleep-wake cycle
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