PET QUESTIONNAIRE

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

MaleFemale
Temperament & Behavior
Overall Temperament:

Loves life and adventureExcitable/nervousWorrier / AnxietyCalm / Pensive / ObserverLoves everyone & attention
When fearful, your pet...

Becomes aggressiveBecomes hysterical/manicBecomes demanding of attentionBecomes wary/unsureHides
Your pet and touch:

Loves a good deep massagePrefers 'tender touch'Any touch, any timeOnly likes some touch from certain peopleWill let YOU know when he/she wants 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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