Health History Consultation Form

Please complete the following information as entirely as you can.

Your Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Your E-mail Address

If you are requesting a consultation for more than one animal, please complete one form for each individual animal.

Which consultation are you requesting?

Advice for a pet with cancer Prevention of dis-ease Raw Feeding

Comments on that above (optional)

How did you hear about us?

The Animal's information

Name

Breed

Gender

Age

Weight

Intact?

Spaced or neutered?

If yes on the above how old when spayed/neutered?

Was there any noticeable physical or emotional change in your companion after being spayed/neutered/sterilized? Yes or No If yes, please explain.

If an intact female, has she ever been pregnant? Yes or No. If so, when? How many litters?

Where did you obtain your animal? (i.e., breeder, shelter, rescue, etc.)

What age was your animal when they came to live with you, and how long have you had him/her?

If from a breeder, do you have health certificate copies of its parents?

General health condition (skin, hair/coat/feather condition, eyes clear, is there a discharge from time to time or every morning, normal stools or loose, lethargic or energetic? etc.). Please attach or email a current photo if possible.

Medical History

Date of last vaccinations: Vaccinated for:

How often is your animal vaccinated and which vaccines are typically given?

Is your companion microchipped? Yes or No If yes, when?

Has your animal been diagnosed by a veterinarian with any illness or health problems? Include any past or recent surgeries. Please list all diagnoses and how long problems have been going on, as well as any symptoms still persisting:

Is your pet currently on any medications? (Include any recent courses of steroids or antibiotics)

If on prescription medications, what were they prescribed for and how long has he/she been on them?

Have there been changes observed since being on the medications? If so, please list:

Is your animal on any parasite prevention drugs? (Heartguard, Frontline, Ivermectin, Advantage, Mycodex, etc.) - Which ones, and for how long?

Does your companion exhibit any of the following physical conditions? (Please explain any yes answer)

Please explain any of the above

Does he/she exhibit any of the following behavior problems? (Please explain any yes answers)

Please explain any of the above

Lifestyle

Describe your companions’ current lifestyle. (Example: how much exercise, how much time spent indoors/outdoors, how much time spent alone, where it sleeps, interactions with other pets/people, favorite toy, how active/playful, etc.) Be as detailed as possible!

Diet

Please detail your animal's current diet? (Include as much information as possible such as brand name/type of food, amount given each day, how long on this particular food, etc.)

How many times have you switched food, and what brands?

List names of all supplements, vitamins, and any other foods, table scraps, or treats your companion receives. Please list everything! - How many treats (estimate) does he/she get per day?

If not currently feeding a species appropriate diet, are you willing to do so? For cats and dogs this is a raw food diet.

Environment

What laundry items and brand do you use?

Do you use air fresheners or burn scented candles? Yes or No. If yes, which ones and how often?

What cleaning products do you use in your home? For floors, counters, furniture, etc.

What products do you use in your yard and garden? Are pesticides/chemical fertilizers used on the lawn?

For cats, what kind of litter do you use?

Have there been any stressful events (moving, changes in schedule or amount of time spent at home, personal stress or tension in home, loss or addition of other animals, etc.) that have coincided with an occurrence or worsening of the companions symptoms/behaviors?

What are your top three concerns for your animal?

What is your feeling/attitude towards your companion's health? (Do you think he/she is healthy/will recover? Or do you often think the worst?)

Please include any other info you feel is important in regards to your animals’ health.

Disclosure Statement

The purpose and general goal of the animal naturopathic consultation offered by Thomas Sandberg is to educate the client about their animals body systems in relation to function and ability pertaining to maintenance of overall homeostasis (balance) through the removal of
various, and typically specific, obstacles to their health, this thereby encouraging their body’s
own natural healing processes.

Thomas Sandberg does not function as a traditional allopathic veterinarian by diagnosing disease, treating disease, or performing invasive procedures, nor do her services replace that of a traditional licensed allopathic veterinarian.

The information offered by Thomas Sandberg is intended to provide general guidance.
Nothing on the website or during a regular consultation constitutes traditional allopathic
veterinary advice. Always consult with a licensed veterinarian before undertaking any course
of “treatment” for your animal or changing treatments or medications your own veterinarian
has already prescribed.

This consultation will hopefully suggest additional options to think about, and other areas to explore, based on your dog's condition.

I, as a mature adult, have read the disclosure statement and understand its content and the
limits of these services. I voluntarily seek these consulting services for my animal and assume
full responsibility for this decision. By completing and submitting this form, this constitutes
my legal signature and acceptance of the services offered by Thomas Sandberg, which will
stand for the initial consultation/coaching date, stated in this disclosure form and for all
subsequent consultations occurring after this date.

On consultations, whether by email or phone, once you've received your consult, there are
no refunds. Refunds are available only if you cancel prior to your appointment 24 hours in
advance (if by phone) or prior to the agreed upon deadline delivery date of your email
consult. Once you have received your consultation, similar to software sales, no refunds are
available at that time.

I have read and agree with the Disclosure Statement:

First Name Last Name

Today's date

Date

I agree that by typing my name above it acts like my legal signature.

Yes, I agree No, I do not agree

Please include any other info you feel is important in regards to your animals’ health.

Payment is required in advance of consult. Once we receive your completed Health
History/Authorization form, we will email you a PayPal invoice.

Cancellation Policy: For cancellations, please contact us at least 24 hours in advance to avoid
being charged.

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Animal Naturopathy Consultation

Health History Consultation Form