Pet Consult Questionnaire
Street Address Line 2
State / Province
Postal / Zip Code
How old when adopted?
Who referred you to Dr. Ruth?
Pet's Primary care veterinarian & contact info
What problem(s) are your pet's experiencing?
When did you notice the problem(s)?
What have you done at home for the problem(s)? Has it been effective?
What medical treatment has your pet received related to the issue?
Please include all currentmedications / dose / how longtaking it / was it helpful?
Please list all supplements being given to pet.
( fish oil, herbs, remedies, etc | dose and how long taking it )
What are you currently feeding your pet?
Any foods that your pet cannot tolerate? what's your pet's reaction to it
Please list any other health conditions your pet has experienced from puppyhood/kittenhood forward?
Is there any time of the day/year or other environmental factor that makes your pet feel better/worse?
What type of exercise does your pet get? and how often?
Does exercise or certain activities make your pet feel better/worse? If so, please describe.
Have you noticed any of the following?
Change in appetite
Change in stools or urine
Change in water consumption
Change in personality
Please explain any checked issues above:
Is it hard to maintain your pets weight, or make them lose/gain weight? Please explain.
Please provide your pet's vaccine history. Was Thuja used after vaccines?
(List types of vaccines and dates if possible)
Has your pet ever been anesthetized? If so, for what?
Please include any issues with recovery from anesthesia.
Does your pet prefer cool or warm areas? Soft or hard surfaces?
Has your pet had abnormal lab tests? If so, please explain.
Does your pet have strange behaviors? If so, please explain.
Does your pet have nightmares or trouble sleeping?
What are other pets in your household?
How does this pet interact with them?
Have there been any changes in your or your pet’s schedule or life?
What are the questions you hope to be answered in this consultation?
What are your goals for your pet's day to day activities? Long term or short term?
Chinese Pet Personality
This portion of our Pet Consultation form package is used to determine which course of action is most appropriate for your pet in terms of Traditional Chinese Medicine. Read through all 5 categories and their traits, mark the boxes of features that relates or describes your pet. Choose all applicable.
loves to be petted
center of the party
rapid heart rate
scared with no reason
likes to hide
slow and consistent
bone and back issues
obeys the rule
relax, laid back
round and large
serine and balance
cares for others (nurturing)
loss of appetite
overeats / obese
anal sack issues
Save and Continue Later
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform