New Client Questionnaire (Canine/Feline) Fields marked with an * are required Date * Owner's Name * Address * City * Zip * Phone * Email * Pet's Name * Primary Veterinarian/Hospital * Pet's Age * Weight * Species * Canine Feline Breed * Sex * Male Female Color * Current Medications * Insurance * Yes No Rabies Vaccine * Yes No Spayed/Neutered * Yes No History of Aggression * Yes No What are your main health concerns for your pet and goals for treatment? * Please list any surgeries or chronic medical issues: * Current medications and supplements (include strength, dose and frequency): * Describe your pet's personality. What are some things that your pet enjoys? What are some things your pet dislikes? * Click the element below that most describes your pet: * Wood: the alpha, decisive, assertive, confident, athletic Fire: life of the party, communicative, friendly, affectionate, lively Earth: relaxed, laid back, sociable, mellow, loyal Metal: obeys the rules, loves order, aloof Water: timid, slow, curious, quiet Describe your pet's appetite. What is your pet's diet? When do you feed them and how much? Include any treats or whole food. Do they eat readily or leave food in the bowl? * Describe your pet's thirst level. Has it increased or decreased recently? * Describe your pet's urination. Are they able to posture normally? Any history of accidents in the house? Any history of UTIs? * Describe your pet's defecation. Are they able to posture normally? Any history of accidents in the house? Do their stools tend to be firm or soft? Historical diarrhea? * Describe your pet's sleep patern. Do they sleep restfully? Where do they sleep? Do they get you up during the night? * Does your pet prefer warm or cool? Do they like to sun themselves outside or do they prefer shade and being on the cool floor? Do they like blankets? * What does your pet do for exercise? Do they like to play with toys? * Any historical vomiting, diarrhea, coughing or sneezing in the last year? Duration? Frequency? * Does your pet have a history of allergies (licking any paws, ear infections, anal gland issues, etc)? If so, is there a seasonal component? * Has your pet had any bloodwork or radiographs in the past year? * Is your pet on heartworm prevention and flea/Tick prevention? Which brand medication? * If you are a human seeing this field, please leave it empty.
