Pacific Animal Hospital / Senior Wellness Program

Pacific Animal Hospital
2801 Oceanside Blvd
Oceanside, CA 92054
(760)757-2442

Welcome to Our Site

Welcome to Our Senior Wellness Program

The following Senior Wellness Survey includes questions regarding past medical history, current health status, and future health and well-being goals. Because pets are unable to speak or write, your pet's doctor will rely on you, the owner/guardian, to provide as much detailed information as possible.

For our valued existing clients and patients, the survey will ensure our records are up to date and complete. For patients new to Pacific Animal Hospital, this document will become the basis for your pet's care.

The Senior Wellness Survey will only take 5 to 10 minutes to complete. If you need assistance filling out the form or have questions, please call our office at 760-757-2442 and we will be happy to help! Once completed online, your survey will be submitted to our office via e-mail. This will ensure the doctor has time to review the survey prior to your pet's comprehensive Senior Wellness Exam. It is helpful, at the time of your appointment, to bring any medications that your pet is currently taking, including supplements and vitamins.

Once you have completed the survey, if you have not already made an appointment, please call us at 760-757-2442 to schedule your pet's Senior Wellness Exam.

Welcome to Pacific Animal Hospital's Senior Wellness Program!

*Owner

*Address

*Phone Number

*Pet's Name

*Pet's Age

*Length of Ownership

*Obtained Pet from ...(Breeder, SPCA, etc.)

*Sex: (Male/Female)

*Neutered/Spayed (Y/N)

*Are your pet's vaccines current? (Y/N)

*Vaccine Type and Date (if done elsewhere)

*Has your pet had a Heartworm Test within the last 12 months? (Y/N)

*Has your pet had a Internal Parasite Test within the last 12 months? (Y/N)

*Is your pet currently taking monthly oral Heartworm Prevention Medication? (Y/N)

Type of Heartworm Prevention Medication?

*Is your pet currently on monthly Flea/Tick control? (Y/N)

*Does your pet travel outside of Southern California?

If Yes, please list where:

*Previous Veterinary Hospital Information:

*Has your pet had previous care at a specialty or emergency hospital? (Y/N)

Do we have your permission to request records? (Y/N)

Has your pet been treated or diagnosed with any of the following: (Please list all that apply):

Eye Problems: infection, tearing, squinting, ulcers, dry eye, glaucoma, vision changes/blindness, tumors, itching, surgery, other:

Ear Problems: infection, hearing loss, itching, tumors, discharge, surgery, head shaking, pain, foreign bodies, parasites, other:

Nose/Mouth Problems: infection, discharge, congestion, sneezing, tumors, pain, trouble opening mouth, trouble chewing, other:

Dental Problems: periodontal disease, infection, extractions, odor, tumors, fractured/broken/missing teeth, other:

Skin/Coat Problems: itching, chewing, licking, fleas, ticks, mites, allergies, licking paws, scooting/anal sac problems, tumors, other:

Heart Problems: murmur, irregular heartbeat/arrhythmia, failure, other:

Lung Problems: coughing, gagging, wheezing, panting, laryngeal paralysis, infection, tumors, trouble breathing, other:

Stomach/Intestinal/Abdominal Problems: vomiting, diarrhea, parasites, dietary sensitivities, hairballs, incontinence, surgery, other:

Bladder/Kidneys/Prostate Problems: urination problems, infection, stones, enlarged/infected prostate, cancer, kidney disease:

Muscle/Bone Problems: limping, surgery, trouble rising, slow on walks, difficulty jumping, reluctant to move, arthritis, tumors, infection:

Neurological Problems: seizures, paralysis/weakness, disorientation, head tilt, back/neck pain, spinal disease, surgery, injury, other:

Behavioral Problems: change in sleep pattern, aggression, restlessness,separation anxiety, noise phobia, disorientation/confusion, other:

Lymph Node Problems: enlargement, infection, cancer:

Dietary Allergies: corn, wheat, chicken, gluten, other:

Does your pet have any known Medication Allergies? (Please list any known):

Has your pet ever had a reaction to vaccinations? (Y/N)

List any swellings, lumps or bumps on your pet's body and length of time present. Have they been checked by a veterinarian?

Have you noticed any limping or trouble moving around, reluctance to jump or go up/down stairs? if yes please describe:

Have you found any slight or profound changes in behavior or sleeping patterns? if yes please describe:

Have there been any changes in the way you and your pet interact?

Would you consider your pet to be enjoying life?

What are the things your pet does everyday that demonstrate happiness and contentment (Please list three to five items):

Do you have any concerns regarding quality of life?

Which aspects of health or well being concern you the most?

Would you like more information on quality of life assessment? (Y/N)

Please describe health concerns and your pet's recent symptoms:

Duration of symptoms (days ,weeks, months):

*How would you describe your pet's appetite? Good/Fair/Poor (Please indicate which one applies):

*What do you feed your pet? Brand/Type/how much and how often you feed:

*How would you describe your pet's water intake: Excessive/No Change/Less (Please indicate which one applies):

*How would you describe your pet's urination habits: Increased/Decreased/No Change/Abnormal, describe:

*How would you describe your pet's defecation habits: Diarrhea/Soft Stool/Normal/Constipation, describe:

*Has your pet had any problems with Coughing: (Y/N)

*Has your pet had any problems with Excessive Panting: (Y/N and time of day if applicable)

*Has your pet had any problems with Sneezing: (Y/N)

*Has your pet had any problems with Nasal Discharge: (Y/N)

*How would you describe your pet's sleep pattern: Increased/Normal/Decreased/Restless (please list any that apply):

*Does your pet experience exhaustion after mild exercise? (Y/N)

*Does your pet experience limping after getting up from sleeping? (Y/N)

*Does your pet experience limping after exercise? (Y/N) please describe:

Which leg(s) seems the most painful?

*Does your pet have any back or neck pain? (Y/N)

Pain Level: 1=least, 9=most

*How would you describe your pet's weight: Overweight/Just right/ Underweight:

*Does your pet itch or have any skin problems? (Y/N)

*Does your pet have fleas or other parasite problems? (Y/N)

Itch Level: 1=least, 9=most

*Is your pet easy to medicate? (Y/N)

*Do you prefer liquid or tablet medications?

*Has your pet had any adverse reactions or allergies to medications?

*Please list all medications (including supplements, vitamins, flea and tick control) with name and dose if possible:

*Please list 3 wellness goals you would like to achieve for your senior pet:

*Please write any specific questions or concerns that you would like to address with the doctor:

Verification Code :
Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.