Client name*
Owner email*
Phone number*
Pet’s name*
Much worseWorseNo ChangeImprovedGreatly Improved
DailyA few times per weekOccasionallyRarelyNot at all
After waking upAfter exercisingDuring cold or damp weatherAt nightNo specific time
Choose one per behavior: Decreased / No Change / Improved
Decreased
No Change
Improved
Activity level
Willingness to play
Ability to go on walks
Jumping/climbing (e.g., stairs, couch)
Appetite
Mood or demeanor
Limping or lamenessReluctance to jump or climbLicking/chewing at jointsHiding or isolatingRestlessness or pacingShaking or tremblingDifficulty standing up or lying downWhining or yelpingAvoiding being touched or handledAggression or irritabilityChange in posture or gait
Vomiting YesNo Diarrhea YesNo Increased drinking YesNo Increased urination YesNo Lethargy YesNo Swelling or redness at injection site YesNo Skin irritation or hair loss YesNo
Other concerns or symptoms noticed
