Species: Canine Feline * Breed:__________ Age:___________

Please complete as much as possible of this history sheet, and bring it in to the hospital on the day your pet
is scheduled to have its Senior Comprehensive Medical Workup.

* CIRCLE APPROPRIATE OPTION Preferred veterinarian to do evaluation?________

Current Diet:

How much fed?______________per day

Vomiting Yes/No * How often?__________ Vomits what?_______
Diarrhoea Yes/No * How often?__________ Colour?___________ Consistency?________ Mucus present? Yes/No * Blood present? Yes/No *
Appetite Normal/lncreased/Decreased *

Thirst Normal/lncreased/Decreased *
Breathing Normal/Excess Panting/Shallow Breaths/Poor Stamina *
Coughing Yes/No * Moist/Dry/Productive * How often?_______________

Sneezing Yes/No * Productive? Yes/No * Type of discharge?_____________________

Urination Normal/Increased amount/Increased frequency/Decreased amount/Decreased frequency *

Blood in Urine? Yes/No * Straining? Yes/No * Accidents in house? Yes/No *

APPEARANCE:
Skin Normal? Yes/No * If not, how?_________________________________

Weight Recent loss? Yes/No * Recent gain? Yes/No * How much?____kg
Please turn over

Hair Coat Normal? Yes/No * Itching? Yes/No * Flaky? Yes/No *

Hair loss? Yes/No * Odour? Yes/No *

Ears Normal? Yes/No * Odour? Yes/No * Hearing OK? Yes/No *

Eyes Normal? Yes/No * Discharge? Yes/No * Sight OK? Yes/No

Difficulty jumping up? Yes/No Difficulty climbing stairs? Yes/No
Increased stiffness or limping? Yes/No Excessive barking/meowing? Yes/No

If so which leg?___________________ Doesn't stand to be petted? Yes/No

Wanders aimlessly? Yes/No Seems disoriented/confused? Yes/No

Stares into space/at walls? Yes/No Difficulty finding right door? Yes/No

Doesn't respond to verbal cues? Yes/No Doesn't respond to name? Yes/No

Sleeps more in the day? Yes/No Decrease in purposeful activity? Yes/No

Urinates indoors? Yes/No Solicits less attention from family? Yes/No

If so how often _________________ Doesn't recognize familiar people? Yes/No

Signals less to go outside? Yes/No Doesn't greet owner? Yes/No

Circling/repetitive movements Yes/No Fainting spells? Yes/No
Seizures? Yes/No Forgets reason for going outdoors? Yes/No

If so how often?___________________ Has tremors or shaking? Yes/No

Gets "stuck" in corners? Yes/No Sleeps less at night? Yes/No

Defecates indoors? Yes/No
If so how often___________ per week

OTHER SYMPTOMS:

If there is anything else we should know, please write below:

CURRENT MEDICATION:

Please note all current medication, dosage and frequency:

If you have noticed any which you would like us to check, please describe in detail below: