Your Information

First Name*

Last Name*

Email*

Phone*

City, State (or province), and Country (if outside of the U.S.)*

How do you prefer to be contacted?*

Phone (U.S. only)WhatsAppOther

We respect your privacy.
Your information will only be used to respond to your inquiry.

About Your Pet

Pet's Name *

Your loved one is a...*

DogCat

Breed*

Weight*

Weight Description*

UnderweightHealthy WeightOverweightUnsure

Age*

Sex*

FemaleMale

Reproductive Status*

Spayed/NeuteredIntactUnsure

Health History

Describe the symptoms your pet is suffering from.*

What is your veterinarian's diagnosis?*

Is there unusual panting that signals distress or pain?*

YesNoSometimes

Any major illnesses or surgeries in your pet's lifetime?

Does your pet suffer from seizures?

YesNo

The following four questions are about seizures. If your pet does not experience seizures, please skip ahead to the Medications and Supplements section.

Before the seizure: what do you notice?

During the seizure: what happens?

After the seizure: how does your pet recover?

Please add any details about the pattern.

If you keep a seizure journal, please email it to pet.consultations@gmail.com along with this evaluation submission.

Medications and Supplements

What medications or prescriptions is your pet currently taking?

Since starting these medications, has there been any improvement?

YesNoToo Early to TellNot Applicable

Please briefly describe.

Please list any supplements, herbs, or homeopathic remedies your pet is currently taking.

Since starting these supplements, has there been any improvement?

YesNoToo Early to TellNot Applicable

Please briefly describe.

Nutrition and Feeding

How often do you feed your pet per day?*

Please list your pet's current food by brand name and type. *

Do you give treats?

YesNo

If yes, what treats do you give?

Has your pet's diet changed recently?

YesNo

How would you describe your pet’s appetite level?

NormalDecreasedIncreasedVariable

Have eating habits changed recently?

YesNo

What type of water do you provide your pet?

FilteredTapBottledOther

Are you treating your pet's water with anything?

Digestion

How often does your pet have bowel movements?

Is gas a problem?

YesNoSometimes

Has the stool changed recently in odor, volume, color, or consistency?

YesNo

If yes, please briefly describe the change.

Urination

Has your pet's daily water intake changed recently?

YesNoUnsure

Is it painful for your pet to urinate?

YesNoUnsure

Are any of the following present with your pet’s urination?

For cat owners only, do you use clumping litter?

YesNo

Skin and Coat

Have there been any changes in your pet's skin or coat?

YesNo

Please briefly describe the change.

How often do you bathe your pet?

What shampoo brand do you use?

Is your pet susceptible to fleas or ticks?

YesNoSometimes

Ears, Eyes, and Oral Health

Please check any that apply to your pet's ears.

Are you currently using anything for ear problems?

Please check any that apply to your pet's oral health.

Bad breathTartar on teethBleeding or infected gumsNone of the above

Body, Joints, and Nervous System

Has your pet's breathing changed?

YesNo

Any cough or wheezing?

YesNo

Emotional and Behavioral Health

Environment

Any vaccinations in the last 3 to 4 months?

YesNo

If yes, any immediate reactions to the vaccinations?

Does your pet wear a chemical flea or tick collar or use flea control products such as Frontline or Advantage?

YesNo

Have you recently sprayed the yard or used chemical pest control inside or outside the home?

YesNo

Do you give a monthly heartworm pill?

YesNo

If yes, what brand?

Any of the following in your pet's environment?

Anything else?

Is there anything else you would like Darleen to know before the consultation?

How did you find For Pet Health?

Pet Evaluation

Your Information

About Your Pet

Health History

Medications and Supplements

Nutrition and Feeding

Digestion

Urination

Skin and Coat

Ears, Eyes, and Oral Health

Body, Joints, and Nervous System

Emotional and Behavioral Health

Environment

Anything else?