Senior Acupuncture Quality of Life Questionnaire

Name: Rouse Hill Family Veterinarian
Address: 10/591 Withers Road, Rouse Hill, NSW, 2155, Australia
Telephone: 02 9086 9130
Price range: $

APPOINTMENT

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Please fill out this form as completely and accurately as possible before your pet’s procedure. If you have questions, don’t hesitate to give us a call at 02-9086-9130.

Name *

Email *

Pet's Name: *

Your full name: *

First

Last

Sleep

Do they sleep through the night? *

Yes
No

House training

Any increase in urination: *

Any urinary accidents? *

Leaking urine when they lay down? *

Yes
No

Is there any faecal incontinence *

Yes
No

Ears, Eyes, Nose and Throat

How is your pets hearing *

Change in bark or meow? *

Yes
No

Meowing or moaning more? *

Yes
No

Any Coughing? If yes, how often? *

Have you noticed any bad breath? *

Yes
No

Has your pet been Panting more frequently? *

Yes
No

Have you noticed any issues with your pets eyesight *

Skin

Are the nails longer than usual? *

Yes
No

Any itching?If so, where abouts? *

Any shivering? *

Yes
No

Any masses or lumps?and if so where? *

Do they smell bad? *

Yes
No

Are they licking or chewing their body? *

Yes
No

Does your cat still groom themselves? *

Yes
No

Environmental preferences

Does your pet seek out certain areas? *

Does your pet seek out areas that Hard or soft? *

Does your pet seek out areas that are sunny or shady? *

Mentation

Does your pet do any of the following? *

Pace during the day
Stare off into space
Show increased aggression

Has your pet experienced any seizures? If yes please explain what happens? *

Exhibit less interaction with family? *

Yes
No

Does your pet act disorientated or distant during the day? *

Yes
No

Does your pet show agitation at certain times of the day? If yes please explain. *

Has your pet found themselves stuck in odd locations? *

Eating and drinking

Has there been any of the following?

Increased thirst? *

Yes
No

Weight loss? *

Yes
No

Weight gain? *

Yes
No

Reduced appetite *

Yes
No

Increased appetite? *

Yes
No

What are you feeding your pet at home? *

Mobility

Does your pet experience any of the following?

Needs assistance to get up? *

Yes
No

Dragging feet or toes? *

Yes
No

Has there been a change in gait or walk? *

Yes
No

Has difficulty jumping? *

Yes
No

Needs assistance climbing stairs? *

Yes
No

What floor type do you have at home? *

Describe your pets exercise levels: *

Has there been a change in exercise levels over the past 12 months? *

Day to Day Life

Describe a good day *

What's your pets' favourite things? *

What do they not like? *

How would you rate your pets quality of life? *

Any other known health issues, medical problems or chronic medications? *

Making a difference when it matters the most

Address

10/591 Withers Road,
Rouse Hill NSW 2155

Click here for directions.

Opening Hours

Monday - Thursday: 9am - 6pm
Friday: 9am - 5pm
Saturday: 9am - 1pm
Sunday & Public Holidays Closed

In-home euthanasia services run outside of opening hours by appointment only

Contact

Phone: 02 9086 9130
Email: hello@rousehillfamilyvets.com.au

Have a question?

Please fill out the form below and a member of our team will be in touch with you shortly. Alternatively please contact us directly at 02 9086 9130.

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