Pet Consult Questionnaire
I'm so glad you're here and taking the first steps to improve your pet's health!
Pet Parent Information
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Information
Pet's name
*
Breed
*
Age
*
Birthdate if applicable
-
Month
-
Day
Year
Date
How old when adopted?
Weight
*
Sex
*
Spayed/Neutered? At what age?
*
Who referred you to Firm Foundation Ranch?
Pet 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 / was it helpful?
Please list all supplements being given to pet.
( Fish Oil, Herbs, Remedies, etc. | Include doses and how long your pet has been 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
Vomiting
Change in stools or urine
Panting
Coughing
Weakness
Disorientation
Change in water consumption
Change in personalty
Other
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 any detox methods 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.
Fire
insomnia
lively
restless
very friendly
communicative
affectionate
loves to be petted
center of the party
separation anxiety
excess heat
rapid heart rate
heart problems
Water
careful
curious
self-contained
likes to hide
meditative
slow and consistent
rear weakness
fearful
bone and back issues
urinary problmes
disturbed growth
deafness
reproductive problems
Earth
relax, laid back
sociable
round and large
loyal
serine and balance
cares for others (nurturing/motherly)
diarrhea
constipation
loss of appetite
vomits
gum disease
weak muscles
overeats/obese
worries
Wood
decisive
assertive
confident
strong
impulsive
athletic stamina
alpha animal
ligament problems
liver problems
red eyes
angers easily
ear problems
nail problems
anal sack issues
footpad problems
Metal
loves order
obeys the rules
aloof
symmetrical body
disciplined attitude
good haircoat
asthma
dry skin
sinus problems
breathing disorder
nose problems
cough
Pet's Primary Care Veterinarian & Contact Info
Upload prior and recent tests results from your local veterinarian including medical information from any visits.
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Upload photos of your pet from the top, sides, and front, and if possible, a picture of the tongue.
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By clicking “ I agree” I understand that this consultation is not a replacement for my veterinarians diagnosis, prescriptions and/or procedures for healing. This consultation will recommend nutrition, supplementation, and lifestyle strategies to complement your veterinarians diagnostic procedures
*
I Agree
By clicking "I Agree" I understand that Firm Foundation Ranch, LLC/Anna Swanson is not qualified to diagnose, prescribe medications, or treat any physical illness, and that nothing discussed during the consultation should be interpreted as such.
*
I Agree
By clicking "I Agree" I agree that Firm Foundation Ranch, LLC/Anna Swanson will not be liable for any adverse reactions or side effects from suggested supplements or dietary changes for my pet. I understand that any changes must be discussed with my veterinarian
*
I Agree
Appointment
*
My Products
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Foundation Package
For pet's with minor health quirks like mild digestive problems, itchy skin, or just need maintenance and prevention.
$
200.00
Cornerstone Package
For pet's with more chronic health hurdles like arthritis, IBS, or kidney concerns.
$
400.00
Pillar Package
For pet's facing severe health battles like chronic disease, cancer, or highly abnormal bloodwork
$
600.00
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