INTEGRATIVE CONSULT INTAKE QUESTIONNAIRE CLIENT INFORMATION * First Name Last Name Date MM DD YYYY Patient's Name * Patient’s D.O.B or Approximate Age * Species * Dog Cat Other Breed * Color/Markings * Sex * Male Female Neutered Spayed Chief Complaint * Previous Medical History * Current Medications and supplements, including dosage * Any history of food or drug sensitivity? Yes No If so, how? Current diet * Does weather, season or time of day affect the symptoms of the main complaint? * Yes No If so, please describe Describe your pet’s personality and how they interact with other animals or people * Does your pet have any fears or phobias? * Yes No If so, please describe Has your pet had any litters? If so, how many? * Date of spay or neuter surgery (if applicable) MM DD YYYY History of any other surgeries or trauma? Vaccine History : Canine DAP/DHPPL/DA2PP Last booster Rabies 1 year Rabies 3 year Bordetella Leptospirosis Lyme Canine Influenza Vaccine History : Feline FVRCP/HCP Last booster FeLV/FIV Test Rabies 1 year Rabies 3 year FeLV Any vaccine reactions? If so, please describe: REVIEW OF SYMPTOMS (Gastrointestinal tract) Flatus Yes No Constipation Yes No Vomiting Yes No Diarrhea Yes No Mucus on Stool Yes No Burping Yes No Borborygymi (noisy intestines) Yes No Incomplete Bowel Movements Yes No Straining to defecate Yes No Fecal Incontinence Yes No REVIEW OF SYMPTOMS (Respiratory) Coughing Yes No Sneezing Yes No Reverse Sneezing Yes No Wheezing Yes No Abnormal breathing Yes No Panting excessively Yes No Snoring Yes No REVIEW OF SYMPTOMS (Cardiovascular) Poor stamina Yes No Heart murmur Yes No Other known heart condition Yes No If yes, please describe REVIEW OF SYMPTOMS (Musculoskeletal) Stiffness Yes No If so, where? Soreness Yes No If so, where? Difficulty getting up or jumping Yes No Worse or better with activity? Muscle wasting Yes No Abnormal gait Yes No Worse or better with rest? REVIEW OF SYMPTOMS (Integument/Skin) Dandruff Yes No Rash Yes No Pruritis (itching) Yes No Oiliness Yes No Hair Loss Yes No Wounds with discharge Yes No Hot spots Yes No Frequent anal gland issues Yes No Location of any lesions REVIEW OF SYMPTOMS (Urologic) Urinary incontinence Yes No Straining to urinate Yes No Cystitis (infection) Yes No Increased urination Yes No Malodorous urine Yes No Color of urine Dark Light Discharge from prepuce or vagina Yes No REVIEW OF SYMPTOMS (Head, ears, eyes, nose, throat) Loss of vision Yes No Cloudiness of lens Yes No Loss of hearing Yes No Discharge from eyes Yes No If so, which eye? Left Right Both Ear infection Yes No If so, which ear? Left Right Both Halitosis Yes No Eye lesions Yes No Oral lesions Yes No Gingivitis Yes No Bad dental disease Yes No Date of last dental REVIEW OF SYMPTOMS (Neurological) Seizures Yes No Head tilt Yes No Incoordination Yes No Dragging limb(s) Yes No General physical signs: Please describe your pet’s characteristics with the following: Appetite: Thirst: Temperature preference (i.e. seeks cool or warm areas): Temperature at various places of the body: Sleep signs (i.e. restlessness, dream filled, deep, falls asleep easily) Energy level in morning vs. afternoon vs. evening If there is any other pertinent information, please list here: Four Paws Wellness Center provides comprehensive veterinary healthcare with an integrative approach. We offer traditional/western diagnostics and treatments as well as holistic therapies including acupuncture, chiropractic, herbal medicine and nutritional counseling. * SIGNATURE (Type Name for Signature) Date * MM DD YYYY Thank you!
