Fill out our online form or download a printable version CLIENT INFORMATIONName for account:*Name of Pet:*Date of Appointment:* Date Format: MM slash DD slash YYYY Time of Appointment:* : HH MM AMPM Date of Birth or Age of Pet:*Sex of Pet:*MaleMale - neuteredFemaleFemale - spayedPrimary issue(s)/concern(s) and approximate duration of each:*DIET TYPES AND DURATIONSCurrent diet and for how long (include treats):*Past diet types and how long:*What was the response to each:*Know or suspected food allergy or intolerances:*VACCINATION AND DRUG HISTORYCurrent supplements or drugs (please list name, strength and how often):*Current supplements or drugs (please list name, strength and how often):*Past drug history (steroids, antibiotic, use (which ones and responses):*Vaccination history (gets all on time, only do minimal vaccinations, don’t do any vaccinations):*Current on heartworm test and preventatives?*YesNoAny reactions to vaccinations?YesNoWhich ones and what happened?*Previous illness history (other than primary concerns):*PERSONALITY/CHINESE CONSTITUTION Wood (the boss) Fire (super excitable but usually friendly) Earth (easy going, friendly, usually food motivated) Metal (I follow all of the rules, don’t get very upset) Water (scared, hides) Become grouchy or bite if doing something he/she doesn’t like?Tends to like areas that: Are very quiet Are very active/exciting AnywhereTEMPERATURE PREFERENCE Cool seeking(hard floors, A/C vents) Heat seeking (warmer bedding, heater vents Seeks out softer spots instead of temperature differencesHate to go out when it is: Hot (Get overheated easily?) ColdIf applicable, are there spots on your pet that feel hot to you?If applicable, are there spots on your pet that feel cold to you?Panting when you think he/she should not (like at rest?)*YesNoWATER CONSUMPTION Less than expected AverageMore than others: Always at the bowl Tanks up all at once Drinks alot throughout the dayAPPETITE Normal Decreased Shows interest but does not eat RavenousPica (eats weird things):NoneStoolGrassGarbageVOMITINGDoes your pet vomit?*YesNoHow often?* Burping a lot after eating Drooling but won’t eatContains: Bile Fur Food (fresh) Food (digested) Blood (black) Blood (red) MucousSTOOL QUALITY Normal Loose Mucoid Bloody (red) Bloody (black) Watery Very DryOdor to stool: Not very smelly Very smellyFlatulance: None Some Too muchSKINTends to be: Normal Dry Greasy Large flake Fine flake Dry lesions Moist lesionsLocations of lesions (if any):Itching tends to be where (if appropriate):Ear issues:COUGHING/SNEEZINGCoughing: None Dry Honking ProductiveWorse In: AM PM All the timeSneezing?YesNoAny discharges from nostrils and which nostril:URINATIONS Normal Little amounts Large amounts/accidents inside Very concentrated (maybe kills grass) Very dilute Unsure of concentrationCONDITION WORSE WITH... Nothing Activity/Movement After laying around Change in weather/heat/cold/dampness At waking or during night timeOr any time listed below: LU (3-5am) LI (5-7am) ST (7-9am) SP (9-11am) HT (11am-1pm) SI (1-3pm) BL (3-5pm) KID (5-7pm) PC (7-9pm) TH (9-11pm) GB (11am-1pm) Liv (1-3pm)Sleeping okay?YesNoLots of dreams?YesNoAGILITY SPECIFIC QUESTIONSWhat venue is run (AKC, USDAA, NADAK, UKC, CPE)?Reason for visit or cause on non-Q?Any refusals, flyoffs, floor slips if not listed above? Please bring any available radiographs (they do not email—files are too large) and lab tests.