Veterinary Alternatives

 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? _______

______________________________________________________________

______________________________________________________________

______________________________________________________________


Circle all that apply:
* Lively                                    * Insomnia

* Communicative                      * Separation Anxiety

* Very friendly                         * Restless

* Affectionate                           * Excess heat

* Loves to be petted                 * Rapid heart rate

* Center of the party                 * Heart problems

* 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

* Relaxed, held back               * Diarrhea

* Sociable                               * Constipation

* Round & large                      * Loss of appetite

* Loyal                                    * Vomits

* Serene & balanced               * Gum disease

* Motherly                               * Weak muscles

* Overeats, obese                    * worries

* Careful                                  * Rear weakness

* Curious                                 * Fearful

* Self contained                       * Bone & back problems

* Likes to hide                         * Urinary problems

* Meditative                            * Disturbed growth

* Slow & consistent                * Deafness

* Reproductive problems

* Loves order                          * Asthma

* Obeys the rules                     * Dry skin

* Aloof                                    * Sinus problems

* Symmetrical body                 * Breathing disorder

* Disciplined attitude               * Nose problems

* Good hair coat                      * Cough