Integrative and Holistic Intake Form
Virtually every form of conventional and holistic medicine for humans, exists for veterinary medicine. Holistic medicine encompasses so many things, however, our main goal is to look at the whole picture of what contributes to your pet's health and well being. That ranges from mental health, environment and diet to alternative and more natural treatments. The more we know about your pet and your interests in integrative and holistic medicine, the more effective we can be at partnering with you on your pet's health. Thank you for taking time to help us learn more about you and your pet.
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State / Province
Postal / Zip Code
Age/Date of Birth
Male - Intact
Male - Neutered
Female - Intact
Female - Spayed
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.
Picture of your pet
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