Name
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First Name
Last Name
Date
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MM
DD
YYYY
Phone Number
*
Is your pet's rabies vaccine up to date?
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Rabies Vaccination Certificate
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Please email a copy of your pet's vaccination certificate to WellnessByShari@verizon.net. This is required prior to your visit.
Pet's Name:
*
Pet's Age:
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Species:
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Sex:
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Breed:
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Neutered/Spayed:
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Reason for seeking sessions:
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How long has your pet been part of your family?
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Where did you obtain your pet?
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When did this specific problem for your pet begin?
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Have the symptoms changed in character over time? If so, how?
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Amelioration/Aggravation Your Pet’s Condition
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Does anything seem to make the problem better or worse? For example, does the problem get better or worse with exercise, being alone, excitement, noise, consolation, touch, warm, cold, damp, or dry weather?
Your Pet's Diet and Water Intake
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What is your pet’s present diet? Please include brand names of pet food, if feeding commercially prepared food, and quantity fed at each meal. If feeding homemade food please be specific in what and how much you’re feeding. Include all treats and extras fed each day.
Does your pet seem to crave any food? If yes, what?
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Was there any change in diet shortly before the onset of the condition?
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Medications and Supplements
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Please list all medications and supplements that your animal is currently taking, including any heartworm or flea preventatives.
Your Pet's Home Environment
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How many family members live in your household, and if you have children, what are there ages?
Do you have other pets in your household? If so, please list them
*
Is your animal mostly an indoor or outdoor pet?
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Friendly:
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Aggressive:
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Fearful:
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Sensitive to noise:
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Sensitive to strangers:
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Timid:
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Worried:
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Indifferent/Resigned:
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Special bond with anyone?
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Overall Attitude:
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