Holistic Intake Form

Holistic Intake Form
Do you have an appointment scheduled?
Full Name

First NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Name
Age/Date of Birth
Sex
Species/Breed
Phone Number

Area CodePhone Number
Previous Vet Hospital
1: What symptoms prompted you to seek medical attention?
2: How do you feel these symptoms are affecting his/her quality of life?
3: How did you hear about us?
4: Have you ever used alternative modalities before?
5: How would you rate their success?
6: How long have you had your pet?
7: What vaccines have been given within the last year?
8: Has s/he ever had and adverse reaction to a vaccine? If so, which vaccine?
9: What do you feed? And how much?
10: Is s/he food motivated?
11: Eats slow or fast?
12: Any likes or dislikes to certain foods?
13: Is s/he sensitive to diet changes?
14: Are dietary changes possible?
15: Would you be able to provide home cooked or prepared meals for your pet?
16: Is s/he easy to medicate?
17: Would s/he accept supplements in food?
18: What is water intake?
19: Is s/he having bowels changes (color, consistancy or frequency)?
20: Has s/he ever had any skin, ear, or eye problems (discharges, lesions, etc...)? If so, how were they treated?
21: Have you heard of Antibody Titers? Has your pet ever been titered?
22: What is your pet's home environment like?
23: Are there other pets in the home?
24: Where does s/he rank among other household members (human and animal)?
25: What is his/her personality like (dominant, submissive, passive, aggressive, etc...)?
26: Does his/her personality change when away from home? How?
27: Has s/he ever expressed any unusual aggresion?
28: Is s/he obedient or stubborn?
29: Is s/he possessive (toys, food, people, etc...)?
30: How does s/he react to strangers? Protective?
31: What mental/emotional observations would you make about him/her? (likes to be fussed over, clingy, independent, etc...)
32: Does s/he have any irrational fears (thunder, fireworks, etc)?
33: How does s/he react to new or unusual situations or people?
34: How does s/he behave when people come to the house?
35: Does s/he exhibit particular symptoms when stressed out?
36: How well does your pet like to travel?
37: How does s/he react to being reprimanded?
38: Have there ever been personality changes? When?
39: Has s/he ever expressed grief? How did you know?
40: Under what circumstances did they grieve?
41: Do you feel that grief caused any physical ailments?
42: Does s/he like to lie in the sun or shade?
43: Where does s/he usually sleep?
44: Does s/he prefer physical activity or a more sedentary life?
45: Has s/he ever displayed any obsessive compulsive behaviors?
46: Is s/he on any medications (list)?
47: Is s/he on any supplements (list)?
48: Has s/he ever had any allergic responses to anything?
49: Is there familial history of disease?
50: When did problem(s) begin? (after vaccine or emotional upset, etc.)
51: How long has the issue been going on?
52: What aggravates problem (time of day/ food)?
53: Is s/he affected by weather? Season?
54: Does s/he act differently at the veterinarian and how?
55: If it is possible, please provide a detailed timeline of symptom occurrence, treatments, lab tests, and medications.
Should be Empty:

Holistic Intake Form

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