This questionnaire helps our veterinary team better understand your senior pet’s daily comfort, mobility, behavior, and overall quality of life.

Please answer each question based on what you are currently observing at home. Your responses will help guide a thoughtful conversation with our veterinarian, but submitting this form does not replace a veterinary examination or consultation.

SLEEP PATTERNS

If No, What Happens During the Night? (Select All That Apply)

HOUSE TRAINING

Has Your Pet Had Any Recent House-Training or Litter-Box Accidents?

EARS, EYES, NOSE, AND THROAT

Have You Noticed Any of the Following? (Select All That Apply)
Have You Noticed Any Vision or Eye Problems? (Select All That Apply)

SKIN AND COAT

Have You Noticed Any of the Following Skin or Coat Changes?

MENTAL AND EMOTIONAL WELL-BEING

Have You Noticed Any of the Following Changes? (Select All That Apply)

EATING AND DRINKING

Have You Noticed Any of the Following Changes? (Select All That Apply)
Please include the food name, approximate daily amount, treats, supplements, and any recent dietary changes.

MOBILITY AND COMFORT

Have You Noticed Any of the Following? (Select All That Apply)

OVERALL QUALITY OF LIFE:

Please discuss the following items in detail with our veterinarians.

Understanding Your Pet’s Life Stage

Use the chart below to compare your pet’s age with the approximate equivalent human life stage based on size.

How Would You Rate Your Pet’s Overall Quality of Life Today?
1: 1 — Very Poor
2: 2
3: 3
4: 4
5: 5 — Fair
6: 6
7: 7
8: 8
9: 9
10: 10 — Excellent

Content developed by Lap of Love