Patient Name...........................................
Nurse.......................................................
Please fill out this questionnaire before attending your appointment. This will help us to fully
assess your pet and give us an idea of how they are at home. If there is anything you are unsure of,
please discuss this with the nurse at your consultation.
Once completed, please email to hayley@worcestervets.co.uk or bring with you to the
appointment.
Please tick all that apply to your dog, even if it only happens occasionally or even just once.
Behaviour
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My dog isn’t acting like himself/herself anymore
My dog interacts with us less/isn’t seeking attention
My dog seems confused/disorientated/displays odd behaviour (circle all that apply)
My dog barks/whines/howls for no apparent reason (circle all that apply)
My dog has started having toileting accidents in the house
Body Functions
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My dog struggles to see/hear things (circle all that apply)
My dog has bad breath/dribbles/eats differently (circle all that apply)
My dog eats more/less than he/she used to (circle one)
My dog has lost/gained weight (circle one)
My dog is drinking more water
My dog is urinating more frequently
My dog’s urine/faeces has changed (circle all that apply)
My dog vomits
Daily Activity
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My dog has difficulty jumping into the car/climbing stairs (circle all that apply)
My dog seems stiff/uncomfortable/painful after exercise(circle all that apply)
My dog is sleeping more often
My dog doesn’t want to play as much anymore
My dog is slower on walks
Skin and Coat
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My dog has new lumps/bumps
My dog has a scruffy coat/matted fur/flaky skin/is itchy(circle all that apply)
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Heart and Lungs
My dog’s breathing has changed
My dog coughs/sneezes (circle all that apply)
My dog pants more/tires easily/doesn’t go as far on walks
Any other comments?
Please tell us about the food and treats your dog usually eats
When was your dog’s last flea and worm treatment administered? What products did you use?
When was your dog last vaccinated?
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Do you brush your dog’s teeth?
Yes
No
Do you groom your dog? If yes, please give details
Thank you for taking the time to complete the questionnaire- it will really help us to make a
thorough assessment of your pet. We look forward to seeing you soon!