Holistic Intake Questionnaire

Holistic Intake Questionnaire

Please fill out the following form.

Client Name
Client Name
First
Last
Patient Name
Patient Name
First
Last
Checkboxes
Any history of food or drug sensitivity?
Does weather, season or time of day affect the symptoms of the main complaint?
Does your pet have any fears or phobias?

Vaccine History

Canine
Feline

Review of Symptoms:

Gastrointestinal tract

Flatus
Vomiting
Constipation
Diarrhea
Mucus on Stool
Burping
Borborygmi (noisy intestines)
Incomplete bowel movements
Straining to defecate
Fecal Incontinence

Respiratory

Coughing
Sneezing
Reverse sneezing
Wheezing
Abnormal breathing
Panting excessively
Snoring

Cardiovascular

Poor stamina
Heart Murmur
Other known heart condition

Musculoskeletal

Stiffness
Soreness
Difficulty getting up or jumping
Muscle wasting
Abnormal gait

Integument/Skin

Dandruff
Rash
Pruritis (itching)
Oiliness
Hair loss
Wounds with discharge
Hot spots
Frequent anal gland issues

Urologic

Urinary incontinence
Straining to urinate
Cystitis (bladder inflammation)
Urinary Tract Infection
Increased urination
Malodorous urine
Color of urine
Discharge from prepuce or vagina

Head, ears, eyes, nose, throat

Loss of vision
Loss of hearing
Discharge from Eyes
Ear Infection
Halitosis
Eye Lesions
Oral Lesions
Gingivitis
Bad dental disease
Was it under anesthesia

Neurological

Seizures
Head tilt

Neurological cont.

Incoordination
Dragging limb(s)

General physical signs

Please describe your pet’s characteristics with the following

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