Client Name (human)
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Subject
*
Home address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient Name (animal)
First Name
Last Name
Patient Age (DOB)
MM
DD
YYYY
Patient Status
Female Spayed
Female Intact
Male Neutered
Male Intact
Patient Breed
Please list your primary reason for seeking consultation:
*
Please list your goals/expectations from seeking this therapy. (i.e. pain control, to discontinue medications, etc.:
Last heartworm prevention given
MM
DD
YYYY
Last flea and tick prevention given
MM
DD
YYYY
Date of last rabies vaccine
MM
DD
YYYY
Date of last distmper/parvo/lepto and bordetella vaccines
MM
DD
YYYY
What testing has been done for diagnosis?
Please list any current medications or supplements your pet takes:
Where did you obtain your pet
Check all that apply.
How long have you had your pet?
< 1 Year
1-2 Years
2-5 Years
5-10 Years
> 10 Years
Did your pet have any issues at the time of adoption?
How long have you and your pet lived in Oklahoma?
< 1 Year
1-2 Years
2-5 Years
5-10 Years
> 10 Years
What are your pet's living conditions?
Check all that apply.
Do you have other pets?
Check all that apply.
Check all that apply regarding your pet's behavior.
Check all that apply.
Have there been any changes in the number of pets in the household in the past year?
Yes, Added 1 or More Pets
Yes, Lost 1 or More Pets
No Change
Where there any issues with your pet during this change?
No, Same Behavior
Yes, Mild Behavior Changes
Yes, Huge Behavior Changes
Describe any changes in your pet's behavior due to this household change.
On a NORMAL day, my pet's attitude toward life, family, and surroundings reflects all of the followint:
Check all that apply.
TODAY, my pet's attitude towards life, family, and surroundings reflects all of the following:
Check all that apply.
My pet is vocal and demonstrates the following:
Check all that apply.
My pet presents the following behaviors:
Check all that apply.
My pet is more:
Check all that apply
My pet shows the following facial expressions:
Check all that apply.
My pet appears confused at what times?
Check all that apply.
My pet appears restless/pacing at what times?
Check all that apply.
My pet has shown the following behaviors in activity
Check all that apply.
When trying to lay down, my pet:
Goes down abruptly, all at once
Is smooth to lay down front to back
Lays down back to front
Takes more than 60 seconds
When trying to stand, my pet:
Is up in less than 5 seconds
Takes 30-60 seconds to stand
Gets up smoothly, all 4 legs at once
Pushes up with front legs first
Pushes up with back legs first
My pet prefers:
Check all that apply.
My pet's sleeping habits show the following:
Check all that apply.
When walking or running, my pet:
Check all that apply.
Concerning posture, I have noticed my pet doing the following:
Check all that apply.
Stiffness is noticeably different at the following times:
Check all that apply.
My pet's exercise routine:
Walks every day
Walks 2-3 times a week
Walks occasionally weekly to every other week
Exercise limited to the yard
Dog park exercise
Cannot exercise due to health issues
No stamina to exercise
Urination habits:
Check all that apply.
Bowel movements:
Check all that apply.
Frequency of soft stool, watery, loose, unformed diarrhea stools:
Daily
Weekly
Every other week
Monthly
Yearly
My pet's appetite is described in what way?
Normal
Decreased
Increased/voracious
Eats very quickly
Eats everything (including non-foodstuff)
Finicky/Choosy
Eats when hungry
Picks at food then walks away
Acts painful while eating
Slow to eat
Please list your pet's diet including products, amount, frequency of feedings, and main protein source in the food: (i.e. Science Diet 1/2 cup twice daily, chicken and barley)
My pet has issues with vomiting:
Check all that apply.
Regarding vomiting:
Check all that apply.
Describe your pet's thirst habits:
My pet has which coughing or breathing issues described below:
Check all that apply.
