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About Us
Services
Resources
Pet Records
Online Pharmacy
- Why You Should Order With Us
- Shop Here
Contact
Book Appointment

A light golden dog with droopy ears lies on a floor

Senior Pet Form

As cats and dogs age, their needs change — and small details help us stay ahead of them. This form lets our veterinary team tailor each visit to your senior pet’s health, comfort, and quality of life.

Get Started

Sharing changes in your pet’s mobility, appetite, or behavior helps our Santa Barbara team catch concerns early and adjust care as your pet grows older.

There are no wrong answers — anything you have noticed is worth telling us.
Not sure whether something is worth mentioning? Call us at (805) 967-0121 or Contact Us, and we will guide you.

Senior Dog Pre-Visit Questionnaire

Thank you for taking a few minutes before your dog's visit. As dogs age, many changes happen gradually at home, where you see them every day and we don't. Your answers help us focus the exam on what matters most to you and your dog. There are no wrong answers, and "not sure" is always fine.

About you and your dog

Your name *

First

Last

Phone *

Email *

Dog's name *

Breed *

Age *

Appointment date *

Date

Time

What are the main things you'd like us to look at during this visit? *

Have you noticed any changes since your dog's last visit?

Yes
No
Not sure

If yes please describe

Eating, drinking, and weight

What food(s) does your dog eat? Include brand, type, and how much per day *

Treats, chews, table food, or anything used to give pills *

Appetite lately *

Increased
Decreased
Normal
Picky or varies

Has your dog's weight changed? *

Gained
Lost
About the same
Not sure

Is your dog drinking more water than before? *

Yes
No
Not sure

Any vomiting, regurgitation, diarrhea, or constipation? *

If yes: please describe.

Mouth and teeth

Have you noticed any of these?

Bad breath
Dropping food
Chewing on one side
Pawing at the mouth
Drooling
Bleeding from the mouth
Avoiding hard food or toys
Swelling of the face
None

Do you brush your dog's teeth or use dental products? *

Yes, daily
Yes, sometimes
No

If yes: which products?

Bathroom habits

Urinating more often or larger amounts? *

Yes
No
Not sure

Accidents in the house? *

If yes: please describe.

Leaking urine while resting or sleeping? *

Yes
No
Not sure

Straining, blood in urine or stool, or changes in stool? *

If yes: please describe.

Mobility and comfort

Please rate how often you see each of these. 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Daily

Stiffness, especially after resting *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Difficulty getting up or lying down *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Reluctance or trouble with stairs, jumping into the car, or onto furniture *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Slipping on smooth floors *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Limping, or favoring a leg *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Lagging behind or stopping early on walks *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Licking or chewing at joints or one area of the body *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Overall, how is your dog's mobility compared with 6 months ago? *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

How long is a typical walk now? *

Upload a short video of your dog walking or getting up

Drag & Drop Files, Choose Files to Upload

Behavior, sleep, and thinking

Please rate how often you see each of these. 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Daily

Seems lost or confused in familiar places, or stares at walls *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Gets stuck in corners or behind furniture *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Doesn't recognize familiar people or pets *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Less interested in greeting, play, or attention, or more clingy than before *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Sleeps more during the day, or is awake or restless at night *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Barks, whines, or vocalizes at night *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Pacing or wandering without purpose *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Forgets house-training or learned cues *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

More anxious, fearful, or irritable (for example, with noises, being alone, or being touched) *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Have you noticed changes in hearing or vision?

Hearing
Vision
Both
Neither
Not sure

Breathing, energy, and body

Coughing, gagging, or noisy breathing? (Frequency) *

Tires more easily, or seems short of breath with activity? *

Yes
No
Not sure

Any fainting, collapse, or episodes of weakness? *

If yes: please describe.

Any seizures or tremors? *

If yes: please describe.

New or changing lumps or bumps? *

If yes: where, and how long?

Skin or coat changes, itching, or ear problems? *

If yes: please describe.

Medications and supplements

List all medications, supplements, and joint or calming products, with how much and how often *

Upload photo

Drag & Drop Files, Choose Files to Upload

Flea, tick, and heartworm prevention used *

Any side effects or trouble with current medications? *

If yes: please describe.

How easy is it to give your dog medication? *

Easy
Somewhat hard
Very hard

Preferred form *

Pill
Liquid
Chewable
Injection
No preference

Quality of life and your goals

On a scale of 1 to 10, how would you rate your dog's overall quality of life right now?

Selected Value: 1

What are your dog's favorite things to do? Is your dog still able to enjoy them?

More good days than bad days lately? *

Mostly good
Mix
Mostly bad

What matters most to you in your dog's care right now? *

Catching problems early
Keeping my dog comfortable
Keeping visits low-stress
Managing costs
Keeping home care simple

Would you like information about comfort care, hospice, or planning ahead for later stages of life? *

Yes
Not right now

The visit itself

How does your dog handle car rides and vet visits? *

Relaxed
A little nervous
Very stressed

Would you like to talk about medication or other ways to make visits easier? *

Is there anything else you'd like us to know?

Please fast your dog before the appointment in case the doctor recommends bloodwork. No food for 8 to 12 hours beforehand; water is fine. If your dog has diabetes or takes medication that must be given with food, please call us at (805) 967-0121 before the visit. Based on the exam and your dog's history, we may also request a urine sample and further lab testing.

Senior Cat Pre-Visit Questionnaire

Thank you for helping us prepare for your cat's visit. Cats are experts at hiding discomfort, so the small changes you notice at home are often the earliest clues we have. Your answers help us keep the visit short, calm, and focused. There are no wrong answers, and "not sure" is always fine.

About you and your cat

Name *

First

Last

Phone

Email *

Cat's name *

Breed *

Age *

Appointment date *

Indoor only, or does your cat go outside? *

Indoor
Outdoor
Both

Other pets in the home?

What are the main things you'd like us to look at during this visit?

Have you noticed any changes since your cat's last visit? *

Yes
No
Not sure

If yes: please describe

Eating, drinking, and weight

What food(s) does your cat eat? Include brand, wet or dry, and how much per day

Treats, or anything used to give pills *

Appetite lately *

Increased
Normal
Decreased
Picky or varies

Has your cat's weight changed? *

Gained
Lost
About the same
Not sure

Losing weight even though eating well or more than usual? *

Yes
No
Not sure

Drinking more water than before (for example, emptying the bowl faster, or drinking from taps or glasses)? *

Yes
No
Not sure

How often does your cat vomit or bring up hairballs? *

Never
Less than once a month
1–3 times a month
Weekly or more

Mouth and teeth

Have you noticed any of these? *

Bad breath
Dropping food
Chewing on one side
Pawing at the mouth
Drooling
Preferring soft food
Chattering jaw
Approaching food then walking away
None

Do you brush your cat's teeth or use dental products? *

Yes, daily
Yes, sometimes
No

Litter box

Are the urine clumps larger, or is there more urine than before? *

Yes
No
Not sure

Going outside the litter box? *

If yes: urine, stool, or both? Where?

Straining, crying, or frequent trips to the box? *

Stool changes *

Hard
Dry
Small stools
Diarrhea
Stool left outside the box

Trouble climbing into the box, or urinating or passing stool over the edge? *

Yes
No
Not sure

Litter box details: how many boxes, type (covered or open, high or low sides), and location *

Mobility and comfort

Cats rarely limp. Instead, look for changes in everyday activities. Please rate how often you see each of these. 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Daily

Hesitates, or no longer jumps up to favorite places (bed, counters, window sill)

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Jumps down awkwardly or with a thump

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Trouble with stairs, or takes them one at a time

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Grooms less, or has a greasy, matted, or scruffy coat (especially along the back)

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Scratches less, or claws are overgrown or thick

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Plays or explores less

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Sleeps or rests more, or in new, lower places

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Less tolerant of being picked up, petted along the back, or brushed

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Overall, how is your cat's mobility compared with 6 months ago?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Upload a short video of your cat walking or jumping

Drag & Drop Files, Choose Files to Upload

Behavior, sleep, and thinking

Please rate how often you see each of these. 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Daily

Loud or unusual crying, especially at night

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Seems lost or confused in familiar places, or stares into space

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Less interested in people or other pets, or more clingy and attention-seeking

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Sleeping more during the day, or restless and awake at night

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Wandering or pacing without purpose

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Hiding more than usual

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

More anxious, irritable, or easily startled

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Forgets routines (for example, where the food bowl or litter box is)

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Have you noticed changes in hearing or vision, or bumping into things? *

Hearing
Vision
Both
Neither
Not sure

Have you noticed enlarged pupils, or sudden trouble seeing? *

Yes
No
Not sure

Breathing and body

Coughing, wheezing, or open-mouth breathing? *

Breathing faster or harder while resting? *

Yes
No
Not sure

Any collapse, weakness, or episodes of wobbliness? *

If yes: please describe

New or changing lumps or bumps? *

If yes: please describe

Skin or coat changes, itching, or ear problems? *

If yes: please describe

Medications and supplements

List all medications, supplements, and calming or joint products, with how much and how often. *

Upload photo

Drag & Drop Files, Choose Files to Upload

Flea and parasite prevention used *

Any side effects or trouble with current medications? *

If yes: please describe

How easy is it to give your cat medication? *

Easy
Somewhat hard
Very hard

clingy your explores

Preferred form *

Pill
Liquid
Treat-based
Transdermal gel
Injection
No preference

Quality of life and your goals.

On a scale of 1 to 10, how would you rate your cat's overall quality of life right now?

Selected Value: 1

What are your cat's favorite things to do? Is your cat still able to enjoy them? *

More good days than bad days lately? *

Mostly good
Mix
Mostly bad

What matters most to you in your cat's care right now? *

Catching problems early
Keeping my cat comfortable
Keeping visits low-stress
Managing costs
Keeping home care simple

Would you like information about comfort care, hospice, or planning ahead for later stages of life? *

Yes
Not right now

The visit itself

How does your cat handle the carrier, car ride, and vet visits? *

Relaxed
A little nervous
Very stressed

Would you like to talk about medication or tips to make visits easier? *

Is there anything else you'd like us to know?

For cat clients: Our cat-only exam room and handling are designed to keep visits calm and quiet. Leaving the carrier out at home for a few days before the visit, with a familiar blanket inside, can help your cat feel more at ease.

Senior lab work reminder: We recommend lab work for senior cats at least once a year. Early changes in kidney, thyroid, and other organ function often show up in blood and urine tests before a cat shows any signs. Based on the exam and your cat's history, we may also request a urine sample and further lab testing.

Schedule Your Pet's Visit Today

Your pet deserves a veterinary team that knows them, listens to you, and treats both of you with warmth and respect. We tailor our medicine to your family’s lifestyle, helping you make the best decisions for your pet. Whether you’re a longtime client or new to the area, we’d love to welcome you to the La Cumbre family.

Call or text (805) 967-0121 or request an appointment online — and discover why Santa Barbara pet families have trusted us since 1959.

Book Appointment

Have a Question?

Please complete our online form and a member of our team will get back to you as quickly as possible.

Name *

First

Last

Email *

Phone

Hidden Field Email

How can we help you? *

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visit Us

Located on State Street in Santa Barbara, just minutes from the Five Points and La Cumbre Plaza area. Stop by to see our Fear Free-designed hospital for yourself.

3910 State St
Santa Barbara, CA 93105

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Get in touch

The fastest way to reach us is by phone, but you can also email us or use our online form anytime that’s convenient for you.

Phone: (805) 967-0121
Text: (805) 967-0121
General questions: info@lcah.com
Medical records: records@lcah.com

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Operating Hours

Open six days a week to care for your pet:

Monday – Friday: 8:00 AM – 5:30 PM
Saturday: 8:00 AM – 3:00 PM
Sunday: Closed