Initial Integrative Intake Form

Step 1 of 4

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Pet Name

Client Name

Date

MM slash DD slash YYYY

Eyes/Ears

Do you have any concerns for your pets eyes or ears?

Does your pet have any redness, discharge, or squinting of the eyes?

Does your pet have a history of any ear infections?

Have you noticed any vision or hearing changes?

Mouth/Teeth

Has your pet ever had a dental procedure or teeth cleaning?

Do you brush your pet’s teeth? If so, how often and what do you use?

Have you noticed any odor, excessive drooling, or sensitivity when eating?

What type of chews do you offer your pet?

Nose/Lungs

Does your pet experience any sneezing or nasal discharge?

Does your pet experience any labored or irregular breathing?

Have you noticed any coughing or hacking?

Digestive Tract/Diet

What treats do you offer your pet? How often?

What food do you feed your pet? How much and how often?

Does your pet have any history or current issue with vomiting? If so, what and how often?

Does your pet have any history or current issue with diarrhea or stool consistency?

Have you noticed any gas or gurgling in your pet’s abdomen?

Skin/Fur/Coat

Have you noticed any changes in your pets coat (dullness, loss, coarseness, etc)?

Does your pet have any past or current issue with itchiness or skin lesions?

Have you noticed any lumps/growths/bumps?

Do you use a flea preventative? If so, what kind and how often?

Do you trim your pet’s nails? How often?

Exercise/Mobility

What sort of exercise does your pet receive? How often?

Have you noticed any limping, stiffness, hesitance to jump, or other mobility concerns?

Are there any sensitive areas on your pet’s body?

Does your pet ever seem painful?

Environment/Emotional

Do you have any other pets in the home? What are their names and ages?

Do all of your pets get along?

Where does your pet stay during the day? Where do they sleep at night?

Does everyone in your household love pet?

Do you use any chemicals in your house or yard?

Are there any stressors in your pet’s life?

How would you describe your pet’s personality?

Major Health History

Has your pet had any major illnesses or injuries? If so, please list:

Does your pet have any history of adverse vaccine or medication reactions? If so, please list:

When did your pet last have blood work performed?

Health Goals

What are your goals for your pet’s health?

What are your primary concerns for your pet?

Do you have any other questions or concerns for today?

*Please bring all supplements or medications that your pet is currently receiving to your appointment* ***Please bring a picture or name and ingredient list of your pet’s diet and treats***

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