Pet Consult Questionnaire

Contact Information
Today's Date

MonthDayYear
Date
Contact Information

Pet Parent Details
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address Line 2

Street Address Line 2

CityCity / State / Province

Postal / Zip Code
Who referred you to Melissa?
Pet Information
Pet's name*
Breed*
Age*
Weight*
Sex*

MaleFemale
Spayed/Neutered? At what age?*
How old when you adopted?*
Pet's Primary Care Veterinarian & Contact Info*
Please acknowledge FDA disclaimer: Medical information or statements made on this site are not intended for use in or as a substitute for the diagnosis or treatment of any health or physical condition or as a substitute for a veterinarian-client relationship which has been established by an in-person evaluation of a patient. This information and advice published or made available through this website is not intended to replace the services of a veterinarian, nor does it constitute a veterinarian-client relationship. Each individual’s treatment and/or results may vary based upon the circumstances, the patients’ specific situation, as well as the health care provider’s medical judgment and only after further discussion of the patient’s specific situation, goals, risks, and benefits and other relevant medical discussions. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent disease.*

Yes, I acknowledge
Pet's Details
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 current medications /dose / how long taking it / is it helpful?*
Please list all supplements being given to pet.*
(Examples include but not limited to: 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? 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 appetiteVomitingChange in stools or urinePantingCoughingWeaknessDisorientationChange in water consumptionChange in personalityNone of the above
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?*
Has your pet ever been anesthetized? If so, for what?*
("put to sleep" or "made unconscious" for a surgery or other reason)
Does your pet prefer cool or warm areas? Soft or hard surfaces?*
Does your pet have strange behaviors? If so, please explain.*
Has your pet had abnormal lab tests? 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.
Water

carefulcuriousself containedlikes to hidemeditativeslow and consistentrear weaknessfearfulbone and back issuesurinary problemsdisturbed growthsdeafnessreproductive problem
Fire

livelycommunicativevery friendlyaffectionateloves to be pettedcenter of the partyinsomniaseparation anxietyexcess heatrapid heart rateheart problemsscared with no reasontongue ulceration
Earth

relax, laid backsociableround and largeloyalserine and balancecares for others (nurturing)diarrheaconstipationloss of appetitevomitgum diseaseweak musclesovereats / obeseworried
Metal

loves orderobeys the rulesaloofsymmetrical bodydisciplined attitudegood haircoatashtmadry skinsinus problemsbreathing disordernose problemscough
Wood

decisiveassertiveconfidentstrongimpulsiveathletic staminaalpha animalsligament problemsliver problemsred eyesangers easilyear problemsnail problemsanal sack issuesseizuresdominantfearlesshasty
Please upload prior and/or recent tests results from your local veterinarian including medical information from any visits.

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Please upload photos of your pet from the top, sides, and front, and if possible, a picture of the tongue.

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Contact Information

Contact Information

Pet Information

Pet's Details

Chinese Pet Personality