Two Legs and Four Holistic Health - Cat, Dog, Small Animal Questionnaire

Two Legs and Four Holistic Health - Cat, Dog, Small Animal Questionnaire
In order to prescribe the best prescription, I depend on your co-operation. Homeopathic treatment is mainly based on the symptoms you provide me. If I am to make a successful prescription, I must know all the details of your pet's problems. I must also understand them as an individual, including their reactions to stress, their past, their nature and their mental make up.

The information you provide enables me to restore their health. So please be frank and free with all relevant information.

Please read each question carefully. Don't keep anything back. Everything you tell me is in complete confidence. This is a lengthy questionnaire, so be prepared to take time to fill it out.

Rather than use he/she, I use the term 'them', 'they'.

You can save the document to complete later. Make sure you click on 'Submit' at the end.

You can fill out as much or as little as you desire. However, the more info I have the better able I can help. Health is complicated and many factors contribute to ill health. Homeopathy examine every possibility.

PLEASE NOTE - THIS FORM DOES NOT AUTOSAVE. YOU HAVE TO CLICK ON THE SAVE BUTTON AT THE END IF YOU NEED TO COME BACK LATER TO FINISH IT
Date*

MonthDayYear
Your name*

First NameLast Name
Preferred Name
Your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Landline Phone

Area CodePhone Number
Cell/Mobile Phone

Area CodePhone Number
E-mail*
Connecting in consultation*

SkypeZoomMadeleine phones youVisit to clinicMadeleine visits you
How did you hear about me?

Internet searchReferral by extended familyReferral by friendAlready treating a family memberOther
If other, please explain
Your pet's name*
Your pet's date of birth or age if known

MonthDayYear
Which animal?*

CatDogOther
What is the breed?
What sex?*

MaleFemale
Entire or sterilised?*

EntireSterilised/neutered
How long have you had your pet?*
Where did they come from?*

BreederPet StoreRescue shelterStreetFamily/friendPrivate homeOtherOther
If other, please explain
How long did it take them to settle in?
Is your pet exclusively indoor, outdoor or indoor/outdoor?*
Nature, Emotions, Characteristics
What is the nature of your pet? What are their characteristics, peculiarities, habits, etc

Characteristics


Is there unusual irritability?
Is there unusual aggression?
Is there unusual timidity?
Is the mood changeable?
Is there mental dullness?
Is there an apparent loss of memory?
What are their fears?
What are they anxious about?
How to they react to stress?
How do they react to reprimands?

Please elaborate
Current Health Concerns
Describe the chief complaint*
Are there any other complaints/concerns?
What factors influence these concerns? Examples include time of day, eating, temperature, presence of another, seasons, etc.
How do these complaints affect their life?
Please list the medications and health supplements you are administering*
Did something trigger the change in health? Examples include shock, injury, veterinary drug or vaccine, change of diet, boarding, if you were away, a new addition to the family, after friends stayed, etc
When did the problem/s start originally?

General Health, if not part of the problem already detailed


How is the digestion?
Is there unusual vomiting?
What is the stool like?
How often is a stool passedl?
Is there constipation?
Is there diarrhoea?
What is their thirst like?
How much do they urinate?
Is there a kidney issue?
Is there a heart problem?
Is there a breathing problem?
Do you use a commercial flea preparation?
Do you use a commercial wormer?
Is there trembling from cold or fright?
Is the fur thinning?
Is the fur greasy?
Is there coughing, sneezing, reverse sneezing?
Is there any bad itching?
Is there staggering or disorientation?
re the ears hot or cold?
Other

Any comments.

Apparent Pain


Is there crying or signs of pain during the stool?
Is there straining to pass a stool?
Is there sensitivity to touch anywhere?
If so, where?
Is there sensitivity to pressure anywhere?
If so, where?
Are there frequent attempts to urininate?
Is there crying before, during or after urination?
Do they wash excessively after elimination?
Other

Any comments.
Environment

Please check all the factors that influence their current life
Are they adversely affected by any external factors?

SeasonsHot weatherHumidityCold weatherChange in weatherChange in temperatureWindThunderstormsPhases of the moonStuffy or warm roomsSmokeThe sunCloudy weatherDry weatherTime of day or nightRainBeing coveredTravelLying in a particular positionRunningClimbing stairsDescending stairsSittingStandingJumping upMorningAfternoonEveningNightJumping downOther
Please elaborate further

Are they adversely affected by any Internal factors?


Is there restlessness, listless or fidgety?
If so, when?
Are they more lethargic than usual?
Are they rested in their sleep?
What position is their common sleep position?
Is there a reluctance to jump up or down?
If so, which?
Other

Any comments.
Past Health Concerns

Please list past health problems/injuries/traumas with treatments and the approximate age.

	Type	Rough age	Duration	Treatment
Health issues
Health issues
Major injuries
Major Injuries
Shock
Shock
Other

Any comments
If your cat/dog has seen a homeopath before, please detail the remedies given and the effect
If you have used homeopathic remedies on your cat/dog yourself, please give details and the effect
EMF, Chemical History

Please detail any exposure, to your knowledge and the adverse effect and date, if noticed or known
EMF is a huge problem, especially for those living in apartments as everyone’s EMF overlaps everyone else’s. Living close to the phone towers can also be hazardous. Animals are more sensitive to these influences than we are. Please detail your living conditions. I recommend that you download the free 7 Essential Ways To Make Your Home Safe here - https://www.takebackyourpower.net/

Chemical exposure such as garden pesticides, weed killers, fertilisers, household cleaners, etc

	Name	Date	Effect
Garden chemical?
Garden chemical?
Household cleaner?
Household cleaner?
Other?

Any comments
Drug, Vaccine, Surgery History

Drugs used in the past.*

	Name	Date	Date	Date	Date	Date	Date
Corticosteroids
Antibiotics
Other
Other
Other
None

Any comments

Vaccines - F stands for feline (cat), C for canine (dog)*

	Name	Date	Date	Date	Date	Date	Date
Rabies
F parvo
F calici
F herpes
F leukemia
F chlamydia
F bordetella
F immunodeficiency
C distemper
C hepatitis/adeno
C parvo
C parainfluenza
C kennel cough/bordetella
C leptospirosis
C coronavirus
Tetanus
Other
None since kitten/puppy
Never

Any comments such as adverse reactions.
Please detail surgeries/operations with dates/age.
Diet

Please detail the diet with brands*

	Brand
Dry
Canned
Semi dried
Single meal foil
Home made cooked
Raw - brand
Home made raw
Other

Any comments and how the appetite is, how often and how much they drink.

About the food


Is there a desire for a certain food?
Fish?
Fatty food?
Milk?
Salt?
Is there unusual thirst?
If so, more or less?
Is the appetite normal?
Is there weight loss?
Is there hawking or scraping of the throat?
Other

Any comments
Sleep

How are they in their sleep?


Soundly
Restless
Twitching
Mostly on right side
Mostly on left side
Crouched uncomfortably
Snores
Upside-down, relaxed
Are they refreshed by sleep?
Other

Family, Relationships
Please detail other animals in the family and how the relationship is. How is the relationship with the human family memers?
Elimination
Please detail any extra information on the frequency and characteristics of their stool - smell, colour, size, shape, with any peculiarities in position, excess washing after, etc
Please detail any extra information on the frequency and characteristics of their urine - smell, colour, with any peculiarities in position, excess washing after, etc
This section for those with stomatitis, gingivitis, mouth inflammation - for extra information not already given

About the mouth


Is there gum discolouration? If so what colour?
Are the gums swollen?
Do the gums bleed easily?
Is there a discharge from the mouth?
Is there tartar on the teeth?
Are any teeth missing?
Is there salivation?
If so, what is the consistency?
Does it come out in strings?
Is the saliva frothy?
Is there more salivation at night or day?
Is there a bad mouth odour?
Is there pain on eating?
Are there mouth ulcers?
Is there pain on opening the mouth?
Are there cracks at the corner of the mouth?
Is the tongue swollen?
Is the tongue discoloured? If so, what?
Is there resentment at touching the mouth?
Other

About the throat


Is there difficulty on swallowing?
If so, is this more for food or water?
Other

Any comments
For those with renal issues - for extra information not already given


Is there more urine than normal?
Is there less urine than normal?
Is there straining to urinate?
Is the amount of urine passed small?
Is there copious urine?
Is the urine slow to come?
Are there many attempts to urinate?
Is the urine frothy?
Is there mucous left after urination?
Is there a stronger than normal smell?
Is there a stronger than normal colour?
Is there crying on passing urine?
Is there crying after urination?
If you have been to a vet, were deposits/crystals found?
If so, what type?
Is there dribbling of urine or incontinence?
If you have been to a vet, is there kidney degeneration?
Are the kidneys swollen or smaller than normal?
Is only one kidney affected? If so, which one.
Is there more washing of the genital area?
Does this area look more pink/red than normal?
Other

Any other or general comments
Any final comments
Re-scheduling or Cancellations

Homeopathic consultations take time. My appointments are lengthy to discover the core reason for your animal's ill health. So cancellations or failure to make an appointment makes a big impact on my day. Inevitably there are times where you need to re-schedule your appointment. Wherever it is possible, I do appreciate you giving me as much notice as possible, at least 24 hours is preferred. Often, people ring me early in the day for an appointment and it is frustrating for us both when there is apparently no free slot, which ultimately becomes available.Those who fail to attend to a prearranged appointment or don’t give me 24 hour advance notice may be charged for the full consultation. I appreciate your consideration.
Thank you!

CONGRATULATIONS in completing this marathon questionnaire! This is a significant step in your pet's journey to wellness.
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Two Legs and Four Holistic Health - Cat, Dog, Small Animal Questionnaire

Nature, Emotions, Characteristics

Current Health Concerns

Environment

Past Health Concerns

EMF, Chemical History

Drug, Vaccine, Surgery History

Diet

Sleep

Family, Relationships

Elimination

This section for those with stomatitis, gingivitis, mouth inflammation - for extra information not already given

For those with renal issues - for extra information not already given

Re-scheduling or Cancellations

Thank you!