Senior Assessment Form
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1 1 [Senior Assessment Form] Senior Assessment Form Client name: Patient name: Signalment: Date: Use this form to guide a discussion with the owner about the health of their pet. Select the most appropriate responses and add comments as needed. Allow minutes for this interview. Encourage the owner to share any concerns and describe any change in their pet. Overall health (Assess the general status of the patient from the owner s perspective.) Some concerns Deteriorating substantially Very worried Doing well Body condition Seems to be gaining weight Seems to be losing weight Bones are more prominent No changes noted Food intake Describe type and amount, including treats and snacks: Increased Decreased Will eat with encouragement or is finicky Not eating Unchanged
2 2 [Senior Assessment Form] Oral health Odor / bad breath Paws or rubs face Eating with head twisted Drops food whilst eating Avoids contact with face Water intake Estimated intake in a 24 hour period: Increased Decreased Unchanged Urination Increased amount of urine voided Gets up in the night to urinate Urinates in the house if left for more than 4 hours Leaking urine whilst sleeping Wet spots noted on bed or furniture Urine marking in the house Increased efforts difficulty noted whilst urinating Increased posturing to urinate Change in the appearance or odor of urine No change in urinary frequency, volume or habits Defecation Describe frequency and regularity of defecation: Stool appearance is changed Mucus Blood Color has changed Stool is narrower Increased efforts to defecate Increased number of bowel movement Defecates in the house Fecal incontinence No change in stool appearance or habits
3 3 [Senior Assessment Form] Vomiting Occasional vomiting How often? Vomits >1 x week Nature of vomit Food Fluid Yellow Red or red flecks Black or coffee ground appearance None noted Breathing Coughing Labored breathing Abnormal breathing noise Increased panting Change in bark How often? Exercise Reluctant to exercise or disinterested No change in ability to exercise Decreased ability to exercise Fatigues or tires quickly Seems painful when exercising or after exercise No change in exercise habits Mobility Needs assistance to get up on furniture or in to vehicle Seems reluctant to move All the time After exercise Following period of rest Favors a limb Which one(s): Gait seems uneven or has changed Gets around effectively; no help needed
4 4 [Senior Assessment Form] Pain assessment Stiffness noted Difficulty getting settling to rest Lies in strange positions Reluctant to lie down Reluctant to move Favoring a limb Change in gait noted No pain noted Skin and hair Change in haircoat Thinner Different color Coat is patchy Slow growth after clipping or grooming Bald spots Redness Itching or irritation No changes noted in haircoat or skin Lumps and bumps Note all swellings or skin masses noted by owner: (Ask about growth rate, swelling, bleeding, and irritation.) Mentation, vision, hearing Personality seems to have changed Anxious / nervous / fearful Aggressive Seems confused or disoriented Has difficulty navigating unfamiliar areas Has difficulty navigating a dark environment Does not respond when called Seems startled when approached from behind
5 5 [Senior Assessment Form] Medications and supplements Taking prescription medicine(s) By mouth: State drug, dose, frequency: By injection: State drug, dose, frequency: On the skin or ears: State drug, dose, frequency: Taking supplements, vitamins, etc. State drug, dose, frequency: On routine heartworm prophylaxis Name: On routine flea and tick preventative Name: Not currently on any medications or supplements Any other questions/observations/concerns? (Encourage the owner to share any concerns about the pet which have not been mentioned.)
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Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
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