New Client Integrative Consultation Form

First and Last Name (required)

Your Pet's Name (required)

Type of Pet (required)
CanineFelineAvianExoticOther

Briefly describe your pet’s current primary medical problem(s) or the reason for today’s visit. Please note when the problem(s) first started.

What medications, supplements or treatment modalities have been used to treat this problem? Have any of these treatments helped? Did any of them make the condition worse? Please list the medications and supplements, including the doses, that you are currently giving.

Are there any other chronic (long term) conditions your pet has that we need to know about?

Does your pet eat rocks, sticks, grass, strange things? Please explain.

Has your pet ever had abnormal blood test results? Please explain.

Does your pet have any strange behaviors? Please explain.

Any regular episodes of diarrhea, vomiting, anorexia, constipation?

Whom may we thank for referring you and if your pet is under the care of another vet, please list the doctor and hospital’s name and the date of the last visit.

Has your pet had any adverse reactions to medications, vaccines, supplements or foods?

List all foods and treats that your pet eats and has access to daily (include amounts and brand names).

What type of water do you provide your pet (ie filtered, bottled, reverse osmosis, tap)?

Any past accidents or injuries? List any possible scars and/or surgery sites.

What are your goals for this visit and do you have specific questions you’d like answered?

What other pets are in the household and what is their general health status?

Has anyone in your family utilized holistic health care? If so, what modalities?

Where has your pet lived or traveled to in his/her lifetime?

Please complete the following only if you are having any chiropractic or acupuncture performed.

If your pet has had chiropractic in the past, when was the last treatment done?

Does your pet prefer hot or cold temperatures? If a preference, please explain.

Does your pet sleep soundly through the night? If not please explain.

Please verify you are human.