OWNER'S INFORMATION *

First Name

Last Name

GROUP ONE

Dry mouth‐eyes‐nose

1

2

3

Keyed up, fails to calm

1

2

3

Nervous

1

2

3

Unable to relax, startles easily

1

2

3

Obsessive compulsive behavior

1

2

3

Vomits easily w/excitement

1

2

3

Tends toward aggression

1

2

3

Fear biter

1

2

3

Paws sweat readily

1

2

3

High anxiety

1

2

3

Isolates away from family or pets

1

2

3

Afraid of storms, fireworks

1

2

3

Cannot adapt easily to changes in home routine

1

2

3

GROUP TWO

Joint stiffness after arising

1

2

3

Eyes or nose watery

1

2

3

Always seems hungry

1

2

3

Eats dirt

1

2

3

Couch potato‐like attitude

1

2

3

Constipation, diarrhea, alternating

1

2

3

Slow starter, slow mover

1

2

3

Circulation poor, sensitive to cold

1

2

3

Subject to respiratory infection

1

2

3

Sleeps more than used to

1

2

3

Not interested in much of anything including food

1

2

3

GROUP THREE

Trembles, episodes of weakness

1

2

3

Seizures

1

2

3

Disoriented

1

2

3

Increased water consumption

1

2

3

Urinating frequently large amount

1

2

3

Hungry often

1

2

3

Change in appearance of eyes

1

2

3

Weight loss

1

2

3

Behavior changes

1

2

3

Increased sleeping

1

2

3

Decreased activity level

1

2

3

Wheat, rice, corn in diet

1

2

3

Overweight

1

2

3

Can not lose weight with diet

1

2

3

Appetite varies

1

2

3

Eats feces

1

2

3

Passes a lot of gas

1

2

3

GROUP FOUR

Exercise intolerance

1

2

3

Significant loss muscle mass

1

2

3

Fainting, collapse

1

2

3

Cough, especially at rest

1

2

3

Disoriented

1

2

3

Swelling in rear legs

1

2

3

Abdominal enlargement

1

2

3

Rear legs tremble, weak

1

2

3

History of heartworms

1

2

3

Difficulty breathing, shortness of breath

1

2

3

GROUP FIVE

On meds over long time

1

2

3

Stool watery or diarrhea

1

2

3

Appears bloated

1

2

3

Recent onset allergies

1

2

3

Seizures, tremors

1

2

3

Change in appetite

1

2

3

Stands with back arched

1

2

3

Elevated cholesterol, lipase, triglycerides

1

2

3

Lethargic, depressed, restless

1

2

3

Frequent anesthetics, multiple surgeries

1

2

3

Increased shedding

1

2

3

Food sensitivities

1

2

3

Ocular discharge

1

2

3

Red eyes or ears

1

2

3

Swollen puffy eyes

1

2

3

Itching or squinting eyes

1

2

3

Anal Sac problems

1

2

3

Rubs at ears or face

1

2

3

Scooting

1

2

3

Licks or chews at feet or anus

1

2

3

Crusty lip sores

1

2

3

Red tummy

1

2

3

General itchiness

1

2

3

Warts

1

2

3

Sporadic vomit/diarrhea

1

2

3

GROUP SIX

Vomits after fatty meal

1

2

3

History of pancreatitis

1

2

3

Middle‐aged female

1

2

3

Halitosis

1

2

3

Recurrent diarrhea

1

2

3

Intermittent vomiting

1

2

3

Pale‐colored stool

1

2

3

Rancid odor to stool

1

2

3

Poor coat

1

2

3

Stomach distress common

1

2

3

GROUP SEVEN

Hyperactive

1

2

3

Weight loss

1

2

3

Increased skin temperature

1

2

3

Racing heart

1

2

3

Increased shedding

1

2

3

Thinning, sparse coat, bald spots

1

2

3

Dry, scaly skin

1

2

3

Oily, greasy coat

1

2

3

Weak pulse

1

2

3

Elevated blood cholesterol

1

2

3

Cold intolerant, likes warm

1

2

3

Fatty tumors

1

2

3

Depression, mentally dull

1

2

3

Exercise intolerant

1

2

3

Back/neck problems

1

2

3

Increased pigment to skin

1

2

3

Obese or can’t lose weight

1

2

3

Stiff gait

1

2

3

Dry eyes, change in eyes

1

2

3

Weak knee ligaments

1

2

3

Failing memory

1

2

3

Abnormal thirst

1

2

3

Weight gain around rear end

1

2

3

Neutered male retains sexual activity

1

2

3

Abnormal heat cycles of intact females

1

2

3

Intact female: no heat cycle

1

2

3

Excessive water consumption

1

2

3

Increased urination

1

2

3

Abnormal urination

1

2

3

Thin skin

1

2

3

Panting all the time

1

2

3

Respiratory distress

1

2

3

Lethargic

1

2

3

Change in behavior

1

2

3

Pacing

1

2

3

Muscles weak

1

2

3

Decline in arthritic symptoms

1

2

3

Weakness

1

2

3

Depression

1

2

3

Slow heart

1

2

3

Intermittent anorexia

1

2

3

Intermittent vomiting and diarrhea

1

2

3

GROUP EIGHT

Older dog

1

2

3

Difficulty getting up and down

1

2

3

History of knee or hip surgery

1

2

3

Arthritic, degenerative joint disease

1

2

3

Back or disc problems

1

2

3

Losing muscle tone in legs or back

1

2

3

Has had ligaments damaged

1

2

3

Healing fracture in body

1

2

3

Bone spurs or enlarged joints

1

2

3

Suffering from a sprain or strain

1

2

3

Rapidly accumulates tarter on teeth

1

2

3

GROUP NINE

Abnormal/frequent urination

1

2

3

History of bladder infections

1

2

3

Kidney disease

1

2

3

Licking at penis or vulva

1

2

3

History of bladder stones

1

2

3

Leaking urine

1

2

3

Painful urination

1

2

3

Wants to go outside more often

1

2

3

GROUP TEN

Increased shedding

1

2

3

Itching

1

2

3

Red bumps to skin

1

2

3

Scabs or crusts to skin

1

2

3

Dandruff, flaking

1

2

3

Body or ear odor

1

2

3

Skin crawls

1

2

3

Poor fur quality

1

2

3

Sores on skin

1

2

3

Changed skin appearance

1

2

3

Frequent infections

1

2

3

Rubs at ears

1

2

3

Moisture under front/rear legs

1

2

3

Gooey ears

1

2

3

Shakes head

1

2

3

Repeatedly taken prednisone

1

2

3

Odor that returns shortly after bath

1

2

3