Patient History Intake Form | Wholistic Housecalls

Caregiver Name and Address

Email

Who is your primary vet?

Were you referred by anyone?

Pet Name

Pet Age

Pet Breed

Pet Sex

Female

Male

How long have you had your pet?

Please list any back history prior to you obtaining pet (where pet came from, any info on prior illnesses or injuries).

Please describe your primary concerns for seeking holistic care?

Please describe your goals for your pet

Pets Diet (please include everything your pet eats including treats, snacks, and chews. Please include quantities and when in the day you are feeding).

Please list any known food sensitivities

Medications or supplements: Please include brand, strength, quantity, frequency, and how long pet has been taking. This includes routine preventatives.

Please Check which apply

Attitude/Spirit

Strong

Weak

Bright

Depressed

Voice

Loud

Quiet

Normal

Temperature Preferences

Prefers warmth/sun

Prefers cool/shade

Neutral

Other

Skin

Itchy (please list places itchy, how long has been present, and grade on scale of 1/10 with 1 being mildest and 10 most severe. If seasonal please list when its worst)

Gastrointestinal

Vomiting

Yes

No

If yes, vomiting food? how often:

If yes, vomits yellow bile? how often:

If yes, vomits foam/fluid? how often:

Body condition: Have you noticed your pet losing weight? Gaining weight? Generally difficult to keep weight on? Or prone to obesity?

Gas

Yes

No

Burping/belching

Yes

No

Excessive drooling present

Yes

No

Lip licking/lipsmacking present

Yes

No

Urinary

Thirst

Increased

Decreased

No change

Respiratory

List when cough was first noticed

List when sneezing was first noticed

Breathing changes

Increased panting

Previously diagnosed respiratory disease

wheezing

Normal

Neurological

Have you noticed any seizures or tremors?

Does your pet seem uncoordinated?

Yes

No

Mobility

Limping/lameness/stiffness/or soreness: Yes or No

Yes

No

Please list any things you have tried to improve mobility? What has helped, what has not helped?

Please list if any xrays or advanced imaging has been performed, and date: please provide records.

Please list exercise and activities your pet engages in on an average week:

Behavior

Please check any characteristics that describe your pet

Anxious

Fearful

Separation anxiety

Destructive behavior

Abnormal activity (over grooming, eating abnormal things)

Doesn’t like dogs

Doesn’t like cats

Protective of me or another family member

Fearful of loud noises (storms, fireworks)