Instructions Please check all that apply to your dog:
Behavior / Neurologic My dog is just not acting like himself/herself.My dog is not seeking as much attention and interacts less with the family.My dog seems confused or disoriented.My dog has been barking or howling excessively for no apparent reason.My dog's sleeping patterns have changed.My dog has had tremors or episodes of shaking.My dog is slowing down.My dog has been panting excessively. Body Functions My dog has bad breath.My dog has difficulty chewing.My dog's appetite has increased/decreased.My dog is drinking more water than usual.My dog is urinating more frequently than usual.My dog's house-training habits have changed and he/she sometimes has accidents.My dog's bowel habits have changed (increased frequency, diarrhea, constipation, straining).My dog vomits more than occasionally.My dog seems to have trouble seeing or hearing.My dog has been scooting or attempting to lick his/her rear end. Heart / Lungs My dog has been coughing, or seems winded after walking or playing.My dog seems to be panting more. Activity / Orthopedics I have noticed a change in my dog's behavior or activity level.My dog lags behind on walks.My dog has difficulty climbing stairs and jumping.My dog limps, especially after exercise.My dog has lameness (front leg, rear leg, intermittent, persistent) How much and how often does your dog get exercise? Skin and Coat My dog scratches, licks or chews excessively.My dog has changes in haircoat, skin, or new lumps or bumps.My dog's skin has an odor.My dog has bald spots. What foods and treats are you currently feeding your dog? How often? And how much?
Please list current medications/supplements: Do you have any specific questions or concerns about your dog? Pet Name Owner Name Owner Email Date
