Holistic Animal Assessment

Holistic Support Assessment Form
Thank you for taking the time to fill out this form for the purpose of conducting a holistic assessment of your animal.

Our focus is on emotional/behavioral wellbeing but please also include any health issues your animal is dealing with currently or has dealt with in the past. Note that this in no way consitutes medical advice, diagnosis or "treatment" and you should bring all physical health issues to the attention of your licensed veterinarian.

Please let me know if you or your animal are, or could be, pregnant, or on medication. Some essential oils should be avoided in pregnancy or with certain medicines.
GENERAL INFO:
Date*

MonthDayYear
Owner's Full Name*
Contact number (don't forget country code if outside the USA)*
Mailing Address*
E-mail*
Animal's Name*
Nicknames*
Age*
How long ago did you acquire this animal?*
Sex*
Include if neutered/spayed and at what age
Species*
Dog/Cat/Horse/Etc.
Breed*
Would you like to receive updates, news, tips etc. from Holistic Spirit?*

Yes, pleaseNo, thanks
MAIN ISSUE:
Describe the current problem and its history/origin: *
Describe any treatment, current or past, that has been prescribed for this problem by a vet or other holistic or behavioral practitioner:*
Describe your animal's life history (the more detail, the better!)*
Is the condition better or worse at a particular time of year? Time of day? If yes, when: *
I.e. worse in summer, worse at night
PHYSICAL HEALTH

Please describe the condition of each and if there are any issues (past or present)
Respiratory*
Allergies*
Skin condition*
Coat condition*
Nail condition*
Musculo-skeletal problems*
Digestion (Slow? Fast? Easily upset?)*
Please describe your animal's vaccination history (over-vaccination can contribute to health issues): *
Please list date of last shots, and which ones were given:*
De-worming history, including date and type of last dose:*
Reproductive health: describe any issues (past or present), major changes in behavior, false pregnancy, etc. or age when neutered/spayed: *
General health, and any other relevant health history:*
Does the animal live inside/outside?*
Where does he/she sleep?*
How much free time with his/her own species?*
Diet - please list everything you feed, including treats, supplements and "leftovers" given, the protein source of the food (i.e. beef, chicken, etc.), and when fed:*
How much physical exercise does your animal get, and what types?*
How much mental exercise (i.e. training, food puzzles, etc.)?*
YOUR ANIMAL'S TEMPERAMENT:
Basic temperament:*
Attitude to other animals:*
Attitude to work/training:*
Leader or follower? Assertive or not?*
Unusual habits?*
FIVE ELEMENTS

Please pick the statement that best describes your animal for each of the following:
You and your animal go on an adventure, does s/he most typically:*

Relish the experience and come alive (wo)Get excited and nervous (f)Get worried and anxious (e)Assess the situation coolly (m)Would rather go home (wa)
When your animal is scared, s/he will most typically:*

Lash out (wo)Fool around/get hysterical (f)Demand attention (e)Become guarded and spikey (m)Disappear (wa)
Would you describe your animal's approach to life as most typically:*

Forward fast (wo)Curious (f)Lazy (e)Considered (m)Cautious (wa)
The most important thing in your animal's life is:*

Action (wo)Playmates (f)Harmony (e)Personal space (m)A quiet place to retreat to (wa)
Your animal least tolerates:*

Boredom (wo)Isolation (f)Conflict (e)Confusion (m)Noise (wa)
How does your animal like to be touched?*

A good solid pat or massage as a sign of solidarity (wo)Soft caresses (f)Can’t get enough of hugs andattention (e)Doesn’t really like to be touched except by a few special people (m)Will come to you for a cuddle in its own good time (wa)
When your animal is eating s/hewill most typically:*

Keep one eye on the competition (wo)Always be ready to leave for something more interesting (f)Forget anything else exists (e)Pick and choose the best bits andleave the rest (m)Eat because one must (wa)
WOOD:
Does he/she habitually have angry outbursts? (Wo)*

YesNo
Is s/he often impatient? (Wo)*

YesNo
Does s/he enjoy a challenge? (Wo)*

YesNo
FIRE:
Does s/he tend to be dramatically over-reactive? (F)*

YesNo
Can he/she get over-exuberant, especially in company? (F)*

YesNo
Is s/he shy? (F)*

YesNo
EARTH:
Does s/he worry about the well-being of others? (E)*

YesNo
Is he/she emotionally needy? (E)*

YesNo
Does s/he get upset by changes in routine? (E)*

YesNo
METAL:
Is s/he easily offended? (M)*

YesNo
Is s/he sensitive about his/her personal space? (M)*

YesNo
Can s/he seem aloof? (M)*

YesNo
WATER:
Is s/he suspicious of new people or situations? (Wa)*

YesNo
Is s/he easily unsettled? (Wa)*

YesNo
Does s/he often seem to be in his/her own world? (Wa)*

YesNo
ABOUT YOU
Have you had help training this animal? If so, who with?*
What is your animal experience?*
What attracted you to this particular animal (the individual, not the breed)?*
What are your hopes and expectations from this animal?*
What do you like most about this animal?*
What do you like least about this animal?*
What is your basic attitude to life (in one word or short sentence)?*
Is there any other information you think will be relevant?*
If you could ask your animal one thing, what would it be?*
What would you most like to know/understand about your animal?*
Please upload a RECENT photo of your pet (ideally from today/yesterday)*

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WELL DONE! :-)

> If you signed up for a Holistic Emotional Support consultation for your dog:

When I receive this form, I will spend about two hours reviewing the informaion and conducting a full Meridian Balance Assessment which will identify any energetic imbalances in your animal's body. Then you will receive a summary of the findings, along with recommendations on changes you can make in your animal's daily life and essential oils you can use to support your animal's healing process.

> If you signed up for a behavior modification program (i.e. SOS, Good Dog, Lucky Dog):

The summary and recommendations from this assessment will be sent to you after you book your Foundations Lesson, and we will discuss everything during that lesson.
AGREEMENT:

I understand that essential oils are not a replacement for veterinary care, my veterinarian has seen the animal and diagnosed the problem (where relevant) and agreed to me using essential oils. I agree to use the essential oils only as taught and follow the instructions I have been given. I understand that Noy Szefler is available to answer any questions that I might have and if I am in doubt I will contact her via email at: holisticspiritdogtraining@gmail.com
Owner's signature*

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Holistic Support Assessment Form