Surveypoint

Q1

First Name

Full Name

Q2

Last Name

Full Name

Q3

E-mail

Q4

Street Address

Address

Q5

Street Address Line 2

Address

Q6

City

Address

Q7

State / Province

Address

Q8

Postal / Zip Code

Address

Q9

Pet Name

Q10

Age/Date of Birth

Q11

Sex

Please Select

Male - Intact

Male - Neutered

Female - Intact

Female - Spayed

Q12

Species/Breed

Q13

Phone Number

Q14

What symptoms prompted you to seek medical attention?

Q15

How do you feel these symptoms are affecting his/her quality of life?

Q16

How did you hear about us?

Q17

Have you ever used alternative modalities before?

Please Select

Yes

No

Q18

How would you rate their success?

Q19

How long have you had your pet?

Q20

What vaccines have been given within the last year?

Q21

Has s/he ever had and adverse reaction to a vaccine? If so, which vaccine?

Q22

What do you feed? And how much?

Q23

Is s/he food motivated?

Q24

Eats slow or fast?

Q25

Any likes or dislikes to certain foods?

Q26

Is s/he sensitive to diet changes?

Q27

Are dietary changes possible?

Q28

Would you be able to provide home cooked or prepared meals for your pet?

Q29

Is s/he easy to medicate?

Q30

Would s/he accept supplements in food?

Q31

What is water intake?

Q32

Is s/he having bowels changes (color, consistancy or frequency)?

Q33

Has s/he ever had any skin, ear, or eye problems (discharges, lesions, etc...)? If so, how were they treated?

Q34

Have you heard of Antibody Titers? Has your pet ever been titered?

Q35

What is your pet's home environment like?

Q36

Are there other pets in the home?

Q37

Where does s/he rank among other household members (human and animal)?

Q38

What is his/her personality like (dominant, submissive, passive, aggressive, etc...)?

Q39

Does his/her personality change when away from home? How?

Q40

Has s/he ever expressed any unusual aggresion?

Q41

Is s/he obedient or stubborn?

Q42

Is s/he possessive (toys, food, people, etc...)?

Q43

How does s/he react to strangers? Protective?

Q44

What mental/emotional observations would you make about him/her? (likes to be fussed over, clingy, independent, etc...)

Q45

Does s/he have any irrational fears (thunder, fireworks, etc)?

Q46

How does s/he react to new or unusual situations or people?

Q47

How does s/he behave when people come to the house?

Q48

Does s/he exhibit particular symptoms when stressed out?

Q49

How well does your pet like to travel?

Q50

How does s/he react to being reprimanded?

Q51

Have there ever been personality changes? When?

Q52

Has s/he ever expressed grief? How did you know?

Q53

Under what circumstances did they grieve?

Q54

Do you feel that grief caused any physical ailments?

Q55

Does s/he like to lie in the sun or shade?

Q56

Where does s/he usually sleep?

Q57

Does s/he prefer physical activity or a more sedentary life?

Q58

Has s/he ever displayed any obsessive compulsive behaviors?

Q59

Is s/he on any medications (list)?

Q60

Is s/he on any supplements (list)?

Q61

Has s/he ever had any allergic responses to anything?

Q62

Is there familial history of disease?

Q63

When did problem(s) begin? (after vaccine or emotional upset, etc.)

Q64

How long has the issue been going on?

Q65

What aggravates problem (time of day/ food)?

Q66

Is s/he affected by weather? Season?

Q67

Does s/he act differently at the veterinarian and how?

Q68

Acc Integrative And Holistic Intake Form -Form Fill

First Name

Last Name

E-mail

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Pet Name

Age/Date of Birth

Sex

Species/Breed

Phone Number

What symptoms prompted you to seek medical attention?

How do you feel these symptoms are affecting his/her quality of life?

How did you hear about us?

Have you ever used alternative modalities before?

How would you rate their success?

How long have you had your pet?

What vaccines have been given within the last year?

Has s/he ever had and adverse reaction to a vaccine? If so, which vaccine?

What do you feed? And how much?

Is s/he food motivated?

Eats slow or fast?

Any likes or dislikes to certain foods?

Is s/he sensitive to diet changes?

Are dietary changes possible?

Would you be able to provide home cooked or prepared meals for your pet?

Is s/he easy to medicate?

Would s/he accept supplements in food?

What is water intake?

Is s/he having bowels changes (color, consistancy or frequency)?

Has s/he ever had any skin, ear, or eye problems (discharges, lesions, etc...)? If so, how were they treated?

Have you heard of Antibody Titers? Has your pet ever been titered?

What is your pet's home environment like?

Are there other pets in the home?

Where does s/he rank among other household members (human and animal)?

What is his/her personality like (dominant, submissive, passive, aggressive, etc...)?

Does his/her personality change when away from home? How?

Has s/he ever expressed any unusual aggresion?

Is s/he obedient or stubborn?

Is s/he possessive (toys, food, people, etc...)?

How does s/he react to strangers? Protective?

What mental/emotional observations would you make about him/her? (likes to be fussed over, clingy, independent, etc...)

Does s/he have any irrational fears (thunder, fireworks, etc)?

How does s/he react to new or unusual situations or people?

How does s/he behave when people come to the house?

Does s/he exhibit particular symptoms when stressed out?

How well does your pet like to travel?

How does s/he react to being reprimanded?

Have there ever been personality changes? When?

Has s/he ever expressed grief? How did you know?

Under what circumstances did they grieve?

Do you feel that grief caused any physical ailments?

Does s/he like to lie in the sun or shade?

Where does s/he usually sleep?

Does s/he prefer physical activity or a more sedentary life?

Has s/he ever displayed any obsessive compulsive behaviors?

Is s/he on any medications (list)?

Is s/he on any supplements (list)?

Has s/he ever had any allergic responses to anything?

Is there familial history of disease?

When did problem(s) begin? (after vaccine or emotional upset, etc.)

How long has the issue been going on?

What aggravates problem (time of day/ food)?

Is s/he affected by weather? Season?

Does s/he act differently at the veterinarian and how?

If it is possible, please provide a detailed timeline of symptom occurrence, treatments, lab tests, and medications.