Fur Baby Intake Form
For Herbal, Nutrition, and Lifestyle Support
Owner Information
Owner Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
City / State
*
Dog’s Name
*
Breed (or mix)
*
Age
*
Sex
*
Male
Female
Spayed / Neutered
*
Yes
No
Weight (lbs or kg)
*
Primary Veterinarian
Veterinarian Phone
-
Area Code
Phone Number
Main Concerns
What are you hoping to improve for your dog?
*
Select all concerns that apply:
Digestion issues
Skin issues / itching
Allergies
Anxiety / nervousness
Joint pain / mobility
Low energy
Weight gain
Frequent infections
Senior support
Recovery after illness or surgery
Other
How long has this issue been happening?
*
Recent (under 1 month)
1–6 months
6 months – 1 year
Over 1 year
Has your veterinarian diagnosed anything?
Current Diet
What food does your dog eat daily?
*
Brand / type (kibble, raw, homemade, etc)
*
How many times per day do they eat?
*
1
2
3
Free feeding
Do they receive:
Treats
Table food
Raw bones
Supplements
Favorite foods or treats?
Supplements / Medications
Is your dog currently taking any:
Medications
Supplements
Herbs
Please list names and dosage.
Digestion
How is your dog’s appetite?
*
Very strong
Normal
Picky
Low appetite
Stool consistency
*
Firm / healthy
Loose
Diarrhea often
Constipation
Any of the following?
Gas
Vomiting
Bad breath
Excessive thirst
Skin and Coat
How would you describe your dog’s coat?
*
Shiny and healthy
Dry
Dull
Oily
Any of the following?
Itching
Hot spots
Hair loss
Ear infections
Yeasty smell
Skin redness
Energy + Behavior
Energy level
*
Very high
Balanced
Low
Temperament
*
Calm
Anxious
Reactive
Fearful
Aggressive
Very social
Does your dog experience:
Separation anxiety
Pacing / restlessness
Difficulty settling
Movement and Pain
Does your dog show signs of:
Joint stiffness
Limping
Difficulty standing
Slower walking
Trouble with stairs
When did you first notice this?
Environment + Lifestyle
Where does your dog spend most of their time?
*
Indoor
Outdoor
Both
Exercise routine
*
Walks daily
Occasional walks
Yard play
Very little activity
Exposure to:
Pesticides / lawn chemicals
Tick medications
Flea medications
TCM Observation Questions
These help identify energetic patterns.
Does your dog prefer:
*
Cool floors / shade
Warm blankets / sun
Temperature tendency
*
Runs hot / pants often
Balanced
Runs cold / seeks warmth
Water intake
*
Drinks a lot
Normal
Drinks very little
Tongue color (if visible)
Pink
Pale
Red
Purple
Additional Observations
Any other symptoms or behaviors you want me to know?
Goals
What are your top goals for your dog?
Examples: calmer behavior; healthier digestion; improved skin; longevity support
Consent
This wellness plan provides nutritional, herbal, and lifestyle guidance and does not replace veterinary care.
I understand this is complementary wellness guidance.
*
I agree
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tips for using this with your Sacred Rouxts wellness approach
You may optionally upload a photo of your dog, a photo of their tongue (for TCM observation), and recent bloodwork from your vet. These can dramatically improve pattern assessment.
Upload a photo of your dog (optional)
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Upload a photo of your dog's tongue (optional)
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Upload recent bloodwork from your vet (optional)
Upload a File
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Submit
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