QUESTIONAIRE FOR ALTERNATIVE CLIENTS
Please print, complete and bring with you to your first visit.
Date ________________Name____________________________________
Name of animal ________________Breed _________Age _____Sex______
Main problem today? ___________________________________________
Other concerns________________________________________________
Current diet___________________________________________________
What treats are given ___________________________________________
How many and how often________________________________________
Supplements (including vitamins, minerals, herbs, enzymes, etc.)_________
_____________________________________________________________
_____________________________________________________________
Medications___________________________________________________
Why was medication prescribed and when? __________________________
Are you willing to change your pet’s diet? ______ add supplements______
Are you willing to prepare home-cooked food for your pet? ______________
Is there anything that you would like to add about your pet’s symptoms
or history? For example, has there ever been an emotionally upsetting
event in your family that affected the pet’s attitude or activity level? _______
______________________________________________________________
______________________________________________________________
______________________________________________________________
Check all that apply:
FIRE
* Lively * Insomnia
* Communicative * Separation Anxiety
* Very friendly * Restless
* Affectionate * Excess heat
* Loves to be petted * Rapid heart rate
* Center of the party * Heart problems
WOOD
* Decisive * Ligament problems
* Assertive * Liver problems
* Confident * Red eyes
* Strong * Angers easily
* Impulsive * Ear problems
* Athletic stamina * Nail problems
* Alpha animal * Footpad problems
* Anal sac issues
EARTH
* Relaxed, held back * Diarrhea
* Sociable * Constipation
* Round & large * Loss of appetite
* Loyal * Vomits
* Serene & balanced * Gum disease
* Motherly * Weak muscles
* Overeats, obese * worries
WATER
* Careful * Rear weakness
* Curious * Fearful
* Self contained * Bone & back problems
* Likes to hide * Urinary problems
* Meditative * Disturbed growth
* Slow & consistent * Deafness
* Reproductive problems
METAL
* Loves order * Asthma
* Obeys the rules * Dry skin
* Aloof * Sinus problems
* Symmetrical body * Breathing disorder
* Disciplined attitude * Nose problems
* Good hair coat * Cough
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