Holistic Intake Form Get Started Holistic Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Email *Pet SpeciesDogCatPet's Name *Age *Regular Veterinarian *Chief Complaint *Other Problems *Please complete the attached "Personality Profile & Quick Clinical Summary" by checking the applicable items which are current or past issues of importance. If something happened only one time (like vomiting); you do not need to check it off. Then provide more details regarding the issues on the form below. Physical History: Please give any information in your pet's history relating to these specific issues, especially if there has been a recurrent or longstanding problem. More detail is preferable (such as the color of any discharge or skin lesions). *EyesDischargeVision changesCataractsEarsDischargeHearing lossInflammationNoseDischargeRespiratoryForceful or weak breathingCoughingWheezingWeather relatedDigestiveAppetite (ravenous, normal, small, any food preferences or aversions)Thirst (high, low, normal, small sips or tank up)Vomiting (color, time relation to eating, consistency)Stools (mucus, blood, odor, diarrhea/constipation, color)SkinGreasyDryFlakeyItchyRedInfected areasSmellyDraining tractsIndividual lesions or large generalized problemsHeartAny history of circulatory problems?Changes in energy level?Pacing/howling or erratic behavior?Please explainKidney/BladderBlood in urineStraining to urinateCrystals in urineIncreased frequency of urinationIncontinenceNeurologicalSeizuresParalysis/weaknessLeft vs. Right sideBones/Muscles/LigamentsLameness (first occurrence, location, duration, better with motion or rest, worse with cold or damp weather, any detection of warmth or coldness-to touch-in affected area)Weakness in front or rearPlease ExplainHow long has your pet lived with you? *Any other pets in the house? *Is the home environment stressful? *Characterize your pet's personality.Does your pet prefer sun or shade? *SunShadeDoes your pet prefer carpet or tile? *CarpetTileDoes your pet bet or bare floor *Pet BedBare FloorDoes your pet prefer activity or is he/she sedentary? *ActivitySedentaryHow does your pet act when ill? *Is your pet taking any medications or supplements at this time? *NameSubmit
