Holistic Intake Questionnaire Holistic Intake Questionnaire Please fill out the following form. Client Name Client Name First First Last Last Today's Date Patient Name Patient Name First First Last Last Date of Birth Breed Color/Markings Email Cell Phone Checkboxes Male Female Neutered Spayed Chief Complaint Previous medical history Current medications and supplements, including the dosage: Any history of food or drug sensitivity? Yes No If so, how? Current Diet Does weather, season or time of day affect the symptoms of the main complaint? Yes No If so, please describe Describe your pet’s personality and how they interact with other animals or people: Does your pet have any fears or phobias? Yes No If so please describe Has your pet had any litters? If so, how many? Date of spay or neuter surgery: History of any other surgeries or trauma? Vaccine History Canine DA2PP #1 DA2PP #2 DA2PP #3 Last Booster Lepto Rabies 1 year RAbies 3 year Any Vaccine Reactions Feline FVRCP #1 FVRCP #2 FVRCP #3 Last Booster FeLV/FIV Rabies 1 year Rabies 3 year Any Vaccine Reactions Review of Symptoms: Gastrointestinal tract Flatus Yes NO Vomiting Yes No Constipation Yes No Diarrhea Yes No Mucus on Stool Yes No Burping Yes No Borborygmi (noisy intestines) Yes No Incomplete bowel movements Yes No Straining to defecate Yes No Fecal Incontinence Yes No Respiratory Coughing Yes No Sneezing Yes No Reverse sneezing Yes No Wheezing Yes No Abnormal breathing Yes No Panting excessively Yes No Snoring Yes No Cardiovascular Poor stamina Yes No Heart Murmur Yes No Other known heart condition Yes No If Yes, please describe Musculoskeletal Stiffness Yes No If so, where? Soreness Yes No If so, where? Difficulty getting up or jumping Yes No Muscle wasting Yes No Abnormal gait Yes No Integument/Skin Dandruff Yes No Rash Yes No Pruritis (itching) Yes No Oiliness Yes No Hair loss Yes No Wounds with discharge Yes No Hot spots Yes No Frequent anal gland issues Yes No Location of any Lesions Urologic Urinary incontinence Yes No Straining to urinate Yes No Cystitis (bladder inflammation) Yes No Urinary Tract Infection Yes No Increased urination Yes No Malodorous urine Yes No Color of urine Dark Light Pink Red Brown Discharge from prepuce or vagina Yes No Head, ears, eyes, nose, throat Loss of vision Yes No Left Eye Right Eye Both Loss of hearing Yes No Discharge from Eyes Yes No Left Eye Right Eye Both Ear Infection Yes No Left Ear Right Ear Both Halitosis Yes No Eye Lesions Yes No Oral Lesions Yes No Gingivitis Yes No Bad dental disease Yes No Date of last dental exam Was it under anesthesia Yes No Neurological Seizures Yes No Head tilt Yes No Neurological cont. Incoordination Yes No Dragging limb(s) Yes No If so, which limbs / describe General physical signs Please describe your pet’s characteristics with the following Appetite Thirst Temperature preference (i.e. seeks cool or warm areas) Temperature at various places of the body Sleep signs (i.e. restlessness, dream filled, deep, falls asleep easily) Energy level in morning vs. afternoon vs. evening If there is any other pertinent information, please list here: NEPH Information New Earth Pet Healing is a holistic veterinary wellness clinic focusing primarily on Traditional Chinese Medicine, laser therapy, Firefly photon light therapy, Western herbal therapy, Healy Resonance therapy and nutritional therapy. Certain pharmaceuticals are prescribed when necessary. Should patients require anesthesia, radiographs, surgery or other in-hospital procedures, you will be referred to your conventional veterinarian, or to a full-service veterinary hospital in the city of your preference. e-Signature Clear I acknowledge and agree to all terms noted Today's Date If you are human, leave this field blank. Submit
