Your Name *

How did you hear about us? *

Name of Your Pet *

Your Pet's Age *

Your Pet's Sex (Male/Female) *

My pet is: *

Your Pet's Breed *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Presenting Complaint *

Please list the main reason / reason’s you are seeking holistic care for your pet? For example: “I would like to learn more about cooking for my pet” or “I would like to see if acupuncture can help his / her arthritis pain” or “I hear things like turmeric and medicinal mushrooms are good for chronic inflammation but I’m not sure how much to give my pet” or “ I would like to discuss the possible benefits of running vaccine titers rather than vaccinating”

Diet *

Please provide details on the current diet. Be sure to include: commercial foods and their form (kibble or canned), treats (brand, flavor, amount), home-cooked foods and what is the approximate percentage of the diet that is home-cooked

General Well Being

How old was he/she when he became a part of your family? *

Any details on life before your family? *

(i.e. shelter adoption, breeder, etc)

How is the appetite lately? *

(i.e. poor, finicky, good, ravenous)

How is the stool? *

Please include the consistency, frequency, color, and if there is ever any diarrhea.

Any vomiting? *

Yes
No

Any coughing or sneezing?

Yes
No

How is water intake? *

(i.e. increased, decreased, excessively thirsty)

Please provide some details on urination: *

Does he/she urinate for a long period of time or are there multiple short urinations? Any change in color or smell that you can tell?

Medical Questions

Please list any current medical problems *

What medications is your pet currently using? *

What medications have you tried but have discontinued? Why did you discontinue use? *

Are you giving any supplements? *

(i.e. probiotic, vitamin supplement, etc.)

Has he/ she every had an undesirable reaction from a medication? *

What heart worm prevention do you currently use? *

What flea & tick prevention do you currently use? *

Has your pet ever had a reaction to vaccinations? *

Traditional Chinese Veterinary Medicine

Questions that help me determine your pet's constitution and pattern

What is the preferred temperature for your pet? Does he or she prefer tile/cool floor or a warm area in the sun? *

What about a surface preference does he or she prefer a firm floor when resting or a soft bed? *

Would you consider your pet to be hyperactive, high energy, outgoing, confident, strong, shy, tolerant, friendly, timid, aloof? *

(list any that apply)

How does he/she react when greeting a stranger outside the home? What about if a stranger comes into the home? *

Would you consider your pet to be *

Patient
Impatient

Are they sleeping through the night? *

Yes
No

Have you notice any vocalizing or muscle tremors while sleeping? *

Yes
No

Questions Regarding Pain/Stiffness

Does your pet experience any pain/stiffness *

Yes
No

Has your pet ever been in a fight with another dog? *

Yes
No

Has you pet ever tried to snap at or bite a veterinarian? Has your pet ever been muzzled at a vet visit? *

Does your pet have insurance? Do they have the Holistic rider that covers holistic treatments? *

Initial Consultation Questionnaire Form