History intake Form

Your Name*

First Last

Pet's Name*

First

Email*

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Phone - Best Contact #

Tell us about the primary health concern that motivated you to book a holistic consultation for your pet.

Please list any and all symptoms your pet is exhibiting.

Are there things that help a symptom(s) to improve? (E.g. Change in season, time of day, foods, medications/supplements, stress, aspects of the home environment?)

Yes
No

If yes, please list symptom and describe what helps makes it better

Are there things that cause a symptom(s) to worsen?

Yes
No

If yes, please list symptom and describe what causes it to get worse

Have any diagnostics recently been performed for the above primary health concern? (E.g. Lab work, ultrasound, biopsy, etc.)

Yes
No

If yes, please list and share the findings for each

What is your pet’s current diet and/or brand of food they eat? If home prepared, please provide recipe(s).

In the past have you tried other diets with your pet?

Yes
No

If yes, please list diet tried and reason why

Does your pet have any known or suspect food intolerances?

Yes
No

If yes, please list food(s) and the reaction(s) they cause

How is your pet’s appetite and thirst? When/what time(s) does your pet eat each day?

What type of water does your pet drink (check all that apply)

Tap water (city)
Tap water (well)
Reverse Osmosis
Filtered (Brita-type)
Bottled
Other

If other, please specify

Is your pet a messy eater or drinker? Does he/she drool?

Yes
No

If yes, please explain

Does your pet have any oral health concerns? (E.g. Bad breath, tartar, red gums)

Yes
No

If yes, please explain

Does your pet have any known or suspect seasonal or environmental sensitivities?

Yes
No

If yes, please describe sensitivity and reaction(s)

Please provide a list of your pet’s current medications & supplements including dosage and frequency and describe the response to each.

In addition, list your pet’s previous medications & supplements and describe the response to each.

Tell us about your pet’s past medical history. Please share with us any treatment(s) that have been tried and the response(s).

Please specify details about your pet’s vaccine history. (E.g. Vaccine type, how often, reason and if a reaction ever occurred).

Describe your pet’s temperament at home. How does your pet behave with others who live in the house? (Including other pets, if applicable)

When your pet is outside of the home, in both familiar and unfamiliar settings, does their temperament change? How does your pet react when meeting strangers?

Does your pet have any personality quirks, fears, phobias or behavioural challenges?

Yes
No

If yes, please explain

Does your pet enjoy socializing with other pets? Describe how your pet responds to and interacts with other animals.

Describe in detail your pet’s daily routine. Include places you frequent on walks and outings, also include anything special or unique to your pet’s everyday.

Does your pet have stiffness, soreness, lameness, or difficulty getting up or lying down?

Yes
No

If yes, please list which symptom(s) and frequency. If root cause is known please explain

List any areas on your pet that they do not like being touched, groomed, or handled. Please clarify reason why, if known.

Please describe the condition of your pet’s skin and hair/coat. (E.g. Greasy, coarse coat, dander on skin).

Is your pet itchy? Does he/she have rashes? Sores or “hotspots”? Hair loss? Skin eruptions or discharges?

Yes
No

If yes, please list which symptom(s) and describe. If itchy rate the itch on a scale from 1-10

Please enter a number from 1 to 10.

How active is your pet? What ways does your pet get exercise? How often/frequent? How does your pet behave after exercise? How would you rate your pets exercise tolerance?

Does you pet pant excessively? Snore? Experience coughing, sneezing or shortness of breath?

Yes
No

If yes, please list which symptom(s) and frequency. If root cause is known please explain

Tell us about your pet’s sleeping habits.

Where does your pet typically sleep? Does he/she sleep comfortably, or seem restless?

Does your pet prefer to sleep on hard surfaces, or soft? Does he/she favour cool surfaces or warm?

Does your pet sleep through the night, or need to get up to go to the bathroom at night?

Do these preferences change through the day or overnight? Have any of these preferences recently changed?

Does your pet have issues with house soiling?

Yes
No

If yes, please explain

Has your pet experienced episodes of cystitis (bladder infections)? Or urinary incontinence?

Yes
No

If yes, please clarify. If root cause is known please explain

Does your pet have any bathroom or litterbox habits that are unusual or have changed recently?

Yes
No

If yes, please explain

Does your pet experience bloating, tummy rumbles, burping or vomiting? Are there any patterns you’ve observed with these symptoms?

Yes
No

If yes, please explain details of symptom(s) and frequency. If comfortable, describe the appearance of the vomit

Does your pet experience constipation, diarrhea, flatulence/gas? Have you observed any patterns associated with these symptoms?

Yes
No

If yes, please explain details of symptom(s) and frequency. If comfortable, describe the appearance of abnormal bowel movements

Has your pet had any changes in vision or hearing? Have tear stains or eye discharge? Or reoccurring ear infections?

Yes
No

If yes, please list which symptom(s) and frequency. If root cause is known please explain

Other than the health concern you wish to address at the consultation, does your pet have any long-term medical conditions that we should be aware of?

Yes
No

If yes, please explain

Is there anything else you would like us to know about your pet?

Yes
No

If yes, please share

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