Caregiver Name and Address*
Who is your primary vet? *
Were you referred by anyone?*
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.*
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? *
Excessive drooling present*
Lip licking/lipsmacking present*
List when cough was first noticed
List when sneezing was first noticed
Have you noticed any seizures or tremors?*
Does your pet seem uncoordinated? *
Limping/lameness/stiffness/or soreness: Yes or No*
If yes, please check those that apply
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: *
Please check any characteristics that describe your pet*
