Senior Pet Questionnaire Behavior Screen for Older Dogs & Cats Please complete this form to give our team important information about your pet. Owner's Name Pet's Name Pet's Age Breed Appointment Date 1. Locomotory/ambulatory assessment No alterations or debilities notedModest slowness associated with change from youth to adultModerate slowness associated with geriatric agingModerate slowness associated with geriatric aging plus alteration or debility in gaitModerate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs)Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried)Severe slowness, extreme loss of function, and decreased willingness or interest in moving (spends most of time in bed)Paralyzed or refuses to move 2. Appetite assessmentNo alterations in appetiteChange in ability to physically handle foodChange in ability to retain food(vomits or regurgitates)Change in ability to find foodChange in interest in food (may be olfactory)Change in rate of eatingChange in completion of eatingChange in timing of eatingChange in preferred textures 3. Assessment of elimination function Changes in frequency and "accidents" Normal/No ChangeNo change in frequency, no “accidents”Increased frequency, no “accidents”Decreased frequency, no “accidents”Increased frequency with “accidents”Decreased frequency with “accidents”No change in frequency, but “accidents” Bladder control No change in urination control or behaviorLeaks urine when asleepLeaks urine when awakeLeaks urine when awake or asleepFull-stream, uncontrolled urination when asleepFull-stream, uncontrolled urination when awakeFull-stream, uncontrolled urination when awake or asleepNo leakage or uncontrolled urination, all urination controlled, but in inappropriate or undesirable location Bowel control No changes in bowel controlDefecates when asleepDefecates without apparent awarenessDefecates when awake and aware of action, but in inappropriate or undesirable locations Visual acuity: How well do you think the dog or cat sees? No change in visual acuity detected by behavior, appears to see as well as everSome change in acuity not dependent on ambient light conditions.Some change in acuity dependent on ambient light conditionsExtreme change in acuity not dependent on ambient light conditionsExtreme change in acuity dependent on ambient light conditionsBlind Auditory acuity: How well do you think the dog or cat hears? No apparent change in auditory acuitySome hearing lossExtreme hearing lossDeaf Play interactions: If the dog or cat plays with toys, which situation best describes that play? No change in play with toysSlightly decreased interest in toysSlightly decreased ability to play with toysSlightly decreased interest and ability to play with toysExtreme decreased interest in toysExtreme decreased ability to play with toysExtreme decreased interest and ability to play with toys Interactions with people: Which situation best describes that interaction? No change in interaction with peopleRecognizes people but slightly decreased frequency of interactionRecognizes people but greatly decreased frequency of interactionWithdrawal but recognizes peopleDoes not recognize people Interactions with other pets: Which situation best describes that interaction? No change in interaction with other petsRecognizes other pets but slightly decreased frequency of interactionRecognizes other pets but greatly decreased frequency of interactionWithdrawal but recognizes other petsDoes not recognize other petsNo other pets or animal companions in house or social environment Changes in sleep-wake cycle No changes in sleep patternsSleeps more during the daySome change, awakens at night and sleeps more during the dayMuch change, profoundly erratic nocturnal pattern and irregular daytime patternSleeps virtually all day, awake occasionally at nightSleeps almost around the clock Δ