Our Mission
“Inspired by our reverence for the intrinsic bond between pets and humans, we focus on a skilled and intuitive approach to whole care that integrates our wide range of services.
Therefore enhancing the quality of life for those entrusted to us today, tomorrow and always.”

Form - Senior Questionnaire Form

Name (required)
First Name (required)
Last Name (required)
Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Pets Information
Pets Name (required)

Species (required)
(Choose one)
Canine
Feline

Breed (required)

Age (required)

Signs
Does your pet drink more water than he/she did 6 months or a year ago? (required)
Yes
No

Change in amount of urine production? (required)
Yes
No

Unable to hold urine all night or wet spots where he/she sleeps? (required)
Yes
No

Appetite increased? (required)
Yes
No

Appetite decreased? (required)
Yes
No

Vomiting or regurgitation of food after eating? (required)
Yes
No

If Yes, how often and for what length of time? A week? A month? (required)

Diarrhea? (required)
Yes
No

If Yes, how often and for what length of time? A week? A month? (required)

Constipation or straining to defecate? (required)
Yes
No

What consistency are the bowel movements? (required)
Very hard/dry
Soft formed
Watery

Do bowel movements contain blood or mucous? (required)
Yes
No

Weight gain? (required)
Yes
No

Weight loss? (required)
Yes
No

Bad breath or drooling? (required)
Yes
No

Coughing? (required)
Yes
No

If Yes, when is it the worst? (required)

Excessive panting and/or breathing heavily at rest? (required)
Yes
No

Tires easily at exercise? (required)
Yes
No

Increased stiffness, trouble jumping or walking? (required)
Yes
No

Limping? (required)
Yes
No

If Yes, duration and which leg(s)? (required)

Does your dog go outside on walks, dog parks, groomers? (required)
Yes
No
N/A

Does your cat go outside routinely? (required)
Yes
No
N/A

New lumps or bumps? (required)
Yes
No

If Yes, where? (required)

Hair coat thinner or slow to re-grow after clip or shedding? (required)
Yes
No

Noticeable decrease in vision? (required)
Yes
No

Noticeable decrease in hearing? (required)
Yes
No

Other health concerns? (required)

Behavior
What is the current quality of your pet's life? (required)

Is your pet still playful? Affectionate toward you? (required)
Yes
No

Is my pet interested in the activity surrounding him/her? (required)
Yes
No

Does your pet seem tired and withdrawn most of the time? (required)
Yes
No

Do you think your pet is in pain? Why? (required)

Diet Information
What food(s) do you feed? How much? Canned? Dry? (required)

What treats do you give routinely? (required)

Do you give any supplements or vitamins? Which ones? (required)

New Patients
If your pet is a new patient, please provide recent medical history/medications.


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