Pet Consult Form

Pet Consult Intake Form
Contact Information
Pet Parent Name*

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

CityState
Today's date*

MonthDayYear
Date
Pet Information
Pet's name*
Breed*
Age*
Sex

FemaleMale
Weight*
aprox.
How old when brought home?*
Spayed/Neutered? Age?*
Pet's Primary Care Veterinarian & Contact Info*
Who referred you to Marketa - Paws Balance - Holistic Pet Care?*
Pet Details
What exactly would you like me to help you with? Diet, supplements, second opinion, recipes or else - please, specify below.*
If your pet has medical issues how long ago did they start?*
What have you tried at home? Has it been effective? *
What medical treatment has your pet received related to the issue?*
Please include all medications and supplements - dose / how long taking it? *
What are you currently feeding your pet? Wet - Raw - Dry ? What kind and how often? *
Any foods that your pet is sensitive to? What's your pet's reaction to it? Does your pet have any allergies diagnosed by your veterenian? *
Please list any other health conditions your pet has experienced from puppyhood/kittenhood forward?*
What type of exercise does your pet get? and how often?*
Have you noticed any of the following?*

Change in appetiteVomitingChange in stools or urinePantingCoughingWeaknessDisorientationChange in water consumptionChange in personalityOther
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? Feel free to upload documents below or email to holisticpetcoach@gmail.com*
(List types of vaccines and dates if possible)
Has your pet had abnormal lab tests? If so, please explain or email documents to holisticpetcoach@gmail.com*
File Upload

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Has your pet ever been anesthetized? If so, for what? Did you pet have a dentistry done in the past? *
Please include any issues with recovery from anesthesia.
Does your pet prefer cool or warm areas? Soft or hard surfaces?*
Do you have other pets in your household and if yes, how is his/her relantionship with them? *
Have there been any changes in your or your pet’s schedule or life recently?*
What are the questions you hope to be answered in this consultation?*
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.
Fire*

livelycommunicativevery friendlyaffectionateloves to be pettedcenter of the partyinsomniaseparation anxietyexcess heatrapid heart rateheart problmesscared with no reasontongue ulceration
Water*

carefulcuriousself-containedlikes to hidemeditativeslow and consistentrear weaknessfearfulbone and back issuesurinary problmesdisturbed growthdeafnessreproductive problems
Earth*

relax, laid backsociableround and largeloyalserine and balancecares for others (nurturing)diarrheaconstipationloss of appetitevomitgum diseaseweak musclesovereats/obeseworries
Wood*

decisiveassertiveconfidentstrongimpulsiveathletic staminaalpha animalsligament problemsliver problemsred eyesangers easilyear problemsnail problemsanal sack issuesseizuresdominantfearlesshasty
Metal*

loves orderobeys the rulesaloofsymmetrical bodydisciplined attitudegood haircoatasthmadry skinsinus problemsbeathing disordernose problemscough
holisticpetcoach@gmail.com

E-mail any pictures or documents to email above
This consultation is not a replacement for a veterinarian's diagnosis, prescriptions, and/or procedures for healing. This consultation will recommend nutrition, supplementation, and lifestyle strategies to complement your veterinarian's diagnostic procedures.
Should be Empty:

Pet Consult Intake Form

Contact Information

Pet Information

Pet Details

Chinese Pet Personality

holisticpetcoach@gmail.com