Pet Consult Questionnaire
Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pet Information
Pet's name
*
Breed
*
Age
*
Weight
*
Sex
*
Who referred you to Pamela?
*
Pet Details
What problem(s) are your pet's experiencing?
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Please list all symptoms
When did you notice the problem(s)?
*
Example: After vaccines, after eating, etc.
What have you done at home for the problem(s)? Has it been effective?
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What medical treatment has your pet received related to the issue?
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Please include all current medications / dose / how long taking it / was it helpful?
*
Please list all supplements being given to pet.
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( Fish Oil, Herbs, Remedies, etc. | Include doses and how long your pet has been taking it )
What are you currently feeding your pet? (Kibble, Lightly Cooked, Raw, Etc.)
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Any foods that your pet cannot tolerate? What's your pet's reaction or symptoms to it?
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Example: bloat, gas, diarrhea, itchy skin ,etc.
Please list any other health conditions your pet has experienced from puppyhood/kittenhood forward?
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Example: aggression, runny eyes, ear infections, etc.
Is there any time of the day/year or other environmental factor that makes your pet feel better/worse?
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What type of exercise does your pet get? and how often?
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Does exercise or certain activities make your pet feel better/worse? If so, please describe.
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Have you noticed any of the following?
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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:
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Is it hard to maintain your pets weight, or make them lose/gain weight? Please explain.
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Please provide your pet's vaccine history. Was Thuja used after vaccines?
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(List types of vaccines and dates if possible)
Has your pet ever been anesthetized? If so, for what?
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Please include any issues with recovery from anesthesia.
Does your pet prefer cool or warm areas? Soft or hard surfaces?
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Has your pet had lab tests? If so, please explain and were they abnormal .
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Does your pet have strange behaviors? If so, please explain.
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Does your pet have nightmares or trouble sleeping?
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What are other pets in your household?
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How does this pet interact with them?
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Have there been any changes in your or your pet’s schedule or life?
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Example: moved to new. home, death of pet companion , etc.
What are the main concerns you have with your ?
*
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
scared with no reason
tongue ulceration
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
vomit
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
seizures
dominant
fearless
hasty
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
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Spayed/Neutered? Age?
*
How old when adopted or rescued?
*
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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Print
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