Client ____________________ Pet ___________________ Age ___________

How long have you had pet? ____________________________________________________________

What vaccines have been given within the last year? _________________________________________

Has he/she ever had an adverse reaction to a vaccine? ________________________________________

What food do you feed ?_____________________ How much? ________________________________

Is he/she food motivated or indifferent? ____________________ Eats slow or fast? ________________

Have any likes or dislikes of food? _______________________________________________________

Is he/she sensitive to diet changes? ________________  Are dietary changes possible? ______________

Would you be able to provide home cooked meals for your pet? ________________________________

Is he/she easy to medicate? ____________ Would he/she accept supplements in food? ______________

What is water intake? _________________ Big or small laps? _____________ What temp? _________

Is your pet having bowel changes (color, consistency or frequency)?_____________________________

Has your pet ever had any skin, ear, or eye problems (discharges, lesions, etc..) ___________________

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How were they treated? ________________________________________________________________

Have you heard of Antibody Titers? ______________________________________________________

Has your pet ever been titered? (for distemper or parvo) ______________________________________

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What is your petís home environment like? ________________________________________________

Are there other pets in the house? ________________________________________________________

Where does he/she rank among other household members (human and animal)? ___________________

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What is his/her personality like (dominant, submissive, passive, aggressive ,etc.) ___________________

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Does his/her personality change when away from home? ______________________________________

Has he/she ever expressed any unusual aggression? __________________________________________

Is he/she obedient or stubborn? __________________________________________________________

Is he/she possessive? (toys, people, food, etc.) ______________________________________________

How does he/she react to strangers?____________________ Protective? _________________________

What mental or emotional observations would you make about him/her? (likes to be fussed over, is clingy, etc.) __________________________________________________________________________

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Does he/she have any irrational fears (thunder, fireworks, etc)? _________________________________

How does he/she react to new or unusual situations or people? _________________________________

How does he/she behave when people come to the house? _____________________________________

Does he/she exhibit particular symptoms when stressed out? ___________________________________

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How well does your pet like to travel? ____________________________________________________

How does he/she react to being reprimanded? ______________________________________________

Have there ever been personality changes? ________When? ___________________________________

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Has he/she ever expressed grief? __________________ How did you know?______________________

Under what circumstances did they grieve? ________________________________________________

Do you feel that grief caused any physical ailments? _________________________________________

Does he/she like to lie in the sun or shade? _________________________________________________

Where does he/she usually sleep? ________________________________________________________

In what position does he/she lie? _________________________________________________________

Does he/she prefer physical activity or a more sedentary life? __________________________________

Has he/she ever displayed any obsessive compulsive behaviors? ________________________________

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Have you ever used alternative modalities before? ____________________________________________

How would you rate their success?________________________________________________________

What symptoms prompted you to seek medical attention? _____________________________________

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How do you feel these symptoms are affecting his/her quality of life? ____________________________

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Is he/she on any medications (list)? _______________________________________________________

Is he/she on any supplements (list )? ______________________________________________________

Has he/she ever had any allergic responses to anything? ______________________________________

Is there familial history of disease? _______________________________________________________

When did problem(s) begin? (after vaccine or emotional upset, etc. ) ____________________________

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How long has the issue been going on? ____________________________________________________

What aggravates problem (time of day/ food)? ______________________________________________

Is he/she affected by weather? _____________________ Seasons? _____________________________

How does your pet tell you he/she is ill? ___________________________________________________

Does he /she act differently at the veterinarian and how?_______________________________________

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If itís possible, please provide a detailed timeline of symptom occurrence, treatments, lab tests, and medications. ____________________________________________________________________________________

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