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Holistic Intake Form - Bishop Ranch Veterinary Center

Patient Name

Family Name

Age

Regular Veterinarian:

Chief Complaint:

Other Problems:

Please note if you have seen Dr. Kirsten Williams with your pet at Creature Comforts - You do not need to complete these forms.

Please complete the attached "Personality Profile & Quick Clinical Summary" by checking the applicable items which are current or past issues of importance. It something happened only one time (like vomiting); you do not need to check it off. Then provide more details regarding the issues on the form below.

Physical History: Please give any information in your pet's history relating to these specific issues, especially if there has been a recurrent or longstanding problem. More detail is preferable (such as color of any discharge or skin lesions).

Eyes: Discharge? Vision changes? Cataracts?

Ears: Discharge? Hearing loss? Inflammation?

Nose: Discharge?

Respiratory: Forceful or weak breathing? Coughing? Wheezing? Weather related?

Digestive: Appetite (ravenous, normal, small, any food preferences or aversions)? Thirst (high, low, normal, small sips or tank up)? Vomiting (color, time relation to eating, consistency)? Stools (mucus, blood, odor, diarrhea/constipation, color)?

Skin: Greasy? Dry? Flakey? Itchy? Red? Infected areas? Smelly? Draining tracts? Individual lesions or large generalized problems?

Heart: Any history of circulatory problems? Changes in energy level? Pacing/howling or erratic behavior?

Kidney/Bladder: Blood in urine? Straining to urinate? Crystals in urine? Increased frequency of urination? Incontinence?

Neurological: Seizures? Paralysis/weakness? Left vs. Right side?

Bones/Muscles/Ligaments: Lameness (first occurrence, location, duration, better with motion or rest, worse with cold or damp weather, any detection of warmth or coldness-to touch-in affected area)?Weakness in front or rear?

Emotional: How long has your pet lived with you? Any other pets in the house? Is the home environment stressful? Characterize your pet's personality.

General Questions: Does your pet prefer: sun or shade? Carpet or Tile? Pet bed or bare floor? Does your pet prefer activity or is he/she sedentary? How does your pet act when ill? Is your pet taking any medications or supplements at this time?