Whole Pet Evaluation and Consultation

We are looking forward to seeing you and your pet. In order to help us understand your pet’s issues, please complete this questionnaire prior to your appointment. Your answers will help us give your pet the best care possible. Please note: any fields with * are required.

Today's Date(Required)

DD slash MM slash YYYY

Owner's Details

Owner's Name(Required)

First Last

Email(Required)

Phone(Required)

Pet's Details

Pet's Name(Required)

Species of Pet(Required)

Breed of Pet(Required)

Pet's Age(Required)

Sex(Required)

Male

Female

Desexed?(Required)

Yes

Type of work (guard, farm, couch potato, etc.)(Required)

Health complaints (list and describe with length of time)(Required)

Describe hair(Required)

Body Score (1 = very thin, 5 = very fat)(Required)

Describe Diet(Required)

List drugs, medications, and supplements currently taking(Required)

List traumas, surgeries, major illness with dates and outcomes(Required)

General emotional state and pack status(Required)

Living conditions: What percentage of time does your pet spend in the house and outside?(Required)

Below rate your dog’s current condition from 0-3 (0 = not an issue, 1 = very mild or slight, 2 = moderate or occasional, 3 = severe)

Digestive upset(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Eats grass(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Diarrhea(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Loose stools(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Bloat(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Hair dander(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Low body weight(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Decreased appetite(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Bleeds easily(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Fatigued(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Overweight(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Worries(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Respiratory infection(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Coughs dried or clear(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Coughs phlegm(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Easily fatigued(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Shallow breathing(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Dry skin(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Very thirsty(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Dislike hot weather(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Overheats easily(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Dental problems(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Bad breath(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Skin eruptions/hives(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Cysts/tumours(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Dry eyes(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Red eyes(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Watery eyes(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Sensitive to wind(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Eye infections present(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Eye infections past(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Cataracts(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Poor eyesight(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Sensitive to light(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Eczema-damp skin(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Dry itchy skin(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Ear infections past now(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Cancer(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Tumours/growths(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Anxious(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Nervousness(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Irritability(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Easy to anger(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Frustration(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Depression(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Pack leader(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Jealousy(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Flank tenderness/pain(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Males – prostate problems(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Females – litters?(Required)

Yes

Licking paws(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Hard pads(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Cracked nails(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Painful joints(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Knee problems(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Hip problems(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Urinate frequently(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Bladder infections(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Edema/swelling(Required)

0 - not an issue

1 - very mild or slight

2 - moderate or occasional

3 - severe

Diabetic(Required)

Yes

Poor concentration(Required)

Yes

Fatigue(Required)

Yes

Drinks a lot(Required)

Yes

Hind end weakness(Required)

Yes

Painful back(Required)

Yes

Color of urine(Required)

Kidney stones(Required)

Yes

Perspires very easily(Required)

Yes

Cold extremities(Required)

Yes

Rapid weight changes(Required)

Yes

Loose or lost teeth(Required)

Yes

Reduced sexual energy(Required)

Yes

Increased sexual energy(Required)

Yes

Infertility(Required)

Yes

Difficult pregnancies(Required)

Yes

Hypothyroidism(Required)

Yes

Other comments

Comments

This field is for validation purposes and should be left unchanged.

Whole Pet Evaluation and Consultation

Owner's Details

Pet's Details

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