PET QUESTIONNAIRE

Please answer the following questions regarding your pet's overall temperament, physical and emotional symptoms and changes in behavior.

Pet's Name:

Pet's Age:

Sex of Pet

Temperament & Behavior

Overall Temperament:

When fearful, your pet...

Your pet and touch:

Current Health Symptoms

Description of symptoms:

When symptoms occur: ie time of day, after eating, etc.

Coat condition (i.e. dry, oily, falling out)

Discharge (clear, colored, thick, watery) from eyes, ears, nose and/or genitals:

Mood Changes: (anger, restless, fearful, etc.)

Elimination Habits

Urination (frequency, odor, pain):

Defecation (frequency, texture, color, odor, straining):

Qi Assessment (Energy)

Appetite:

Energy (am/pm):

Vomiting (if yes, frequency and time of day)

Changes in thirst?

Changes in heat or cold tolerance?

Nutritrion

Current Diet:

Supplements:

Any Medications:

PET GUARDIAN INFO

Full Name:

Email Address:

Phone Contact:

Best time of day to reach you:

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