Whitney Veterinary Hospital and Cat Care Clinic
Senior Wellness Survey

Pets are living longer these days, thanks to the wonderful people they live with and the great advances in medical care available. As your pet enters his "Senior Years", it is very important to catch problems early - ideally before you are even able to notice symptoms.

Please take a moment to fill out the following survey so that our doctors and staff will be better able to help make your pet's "Senior Years" as happy & healthy as possible.

Pet's
Name______________________
Age_______ Breed__________________________ Sex____
In the Last Year My Pet:

(Please circle all that apply)
Eats More Less Same Not Sure
Drinks More Less Same Not Sure
Weighs More Less Same Not Sure
Coughs Rarely Occasionally 3-5 times
per week
Daily Continually
Cough Is Dry Moist Not Sure
Hearing Same Decreased May be Deaf
Sight Sees well Has Trouble Bumps into
walls
Bowel
Movements
Normal More Less Hard Loose
Urination Increased Decreased Strong Odor Weak Leaking
Joints Still Athletic Stiff & Sore Trouble
with Stairs
Can't get
on bed
any more
Favors Leg
RT or LFT
Behavior Normal Restless
at Night
Whines/Cries
at Night
Seems
Disoriented
at times
  Seems
Confused
My Cat is
Vocalizing
Accidents
in House
Wanders a
Lot
I am concerned about:






Would you be interested in attending an evening "Senior Pet Care" class?       Yes      No

Owner Name_________________________Phone#________________Date_______________

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