Client Intake Questionnaire

1
Your Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.
Area Code
Phone Number
6
Is there anyone else that you would like to add as a contact for this pet?Please Include their Name and Contact # (This would be a member of household/family/friend; we will ask you to provide the name/location of your current veterinarian in one of the upcoming questions)
7
Pet Name* This field is required.
8
Pet Age or Date of Birth* This field is required.
9
Pet Sex* This field is required.
Male
Female
10
Is your Pet Neutered/Spayed?* This field is required.
Yes
No
11
What is the species of your pet?* This field is required.
Dog
Cat
Other
12
What breed is your pet?* This field is required.
13
What color is your pet?* This field is required.
14
What is the reason for your upcoming visit?* This field is required.
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15
Please List any veterinary practice that this pet has visited in the last 2 years.* This field is required.Please Include Clinic Name and City in which it is located
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16
Why did you decide to seek holistic/alternative care for your pet?* This field is required.
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17
What are the goals you hope to attain by coming to Animal Healing Center?* This field is required.
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18
How did you learn about Animal Healing Center?* This field is required.
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19
Why did you choose this individual pet?* This field is required.
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20
What other pets are in the household? Do they get along?* This field is required.
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21
Personality type/behavior (check all that apply)* This field is required.
Happy
Easy Going
Shy
Dominant
Grouchy
Fearful
Pushy
Aggressive
Moody
Needy
Hyperactive
Submissive
Sensitive
Energetic
Prefers Routine
Gets Along W/People
Gets Along W/Cats
Gets Along W/Dogs
22
Please list all problems your pet may have or has had, date of onset and resolution, frequency of symptoms, and severity. Be sure to include any conventional treatments (ie: surgery, antibiotics, steroids) or holistic treatments used (ie: acupuncture, chiropractic, herbs, supplements):* This field is required.
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23
Does your pet take any current medications? Please include flea, tick, and heartworm prevention.* This field is required.
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24
Does your pet take any over-the-counter supplements?* This field is required.
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25
What does your pet eat (home-prepared, raw, kibble, canned)? Please give as much detail as possible. Please list specific brands of commercial food.* This field is required.
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26
Please describe your feeding protocol:* This field is required.
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27
Would you be willing to cook food for your pet?* This field is required.
YESNO
28
What kind of treats does your animal eat (include everything)?* This field is required.
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29
Is water available at all times? How often is it changed? What kind of water (bottled, filtered, tap)?* This field is required.
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30
Does your pet have any dietary sensitivities or food allergies? * This field is required.
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31
Does your pet have any unusual cravings (ie. grass, dirt, rocks, feces, plastic, metal)?* This field is required.
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32
Have there been any major changes in the pet’s household environment (moving, marriage, death of other pet or human, divorce, new pet)?* This field is required.
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33
How would you describe the household environment for your pet (ie. calm, stressful, chaotic, mellow, lonely, crowded)?* This field is required.
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34
Is your pet aggressive? If so, in what situations? * This field is required.
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35
Does your pet have any anxieties (ie. separation, loud noises, etc.)* This field is required.
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36
How does your pet react in new situations? How does your pet react with new people?* This field is required.
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37
Is your pet groomed? If yes, how often? * This field is required.
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38
What shampoo or conditioners are used?* This field is required.
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39
How does your pet get exercise (ie. leash walks only, beach, agility)? * This field is required.
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40
Describe your pet’s activity level and how often he/she gets exercise?* This field is required.
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41
Does your pet have free access to the outdoors? If so, how big is the yard?* This field is required.
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42
Please list all the people and animals currently living in the household:* This field is required.
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43
Does anyone in the household receive holistic medical treatment (ie. acupuncture, chiropractic care, massage, supplements)? If yes, please describe.* This field is required.
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44
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