Holistic intake form

Client Name*

First

Last
Spouse/Partner Name

First

Last
Address*

Street Address

City

State

ZIP Code
Client's Primary Phone*
Spouse/Partner Phone
Email*
How would you prefer to be contacted?
- Phone
- Text
- Email
Pet's Name*
Pet's Age*
Pet's Gender
- Male
- Female
Spayed/Neutered
- Yes
- No
Is your pet microchipped?
- Yes
- No
Do you have pet insurance?
- Yes
- No
Species
Breed
Weight
Additional Questions
Primary complaint*
Duration of problem*
Past treatments for this condition
Diet & Amount fed (Please list specific brand, dry/canned, as well as any treats regularly given)*
How is your pet’s appetite?*
- Normal
- Increased
- Decreased
- My pet loves to eat
- My pet is picky
- My pet is not food motivated
Does your pet have any food allergies?
How is your pet’s water intake?*
- Increased
- Decreased
- Frequent small sips
- Large amounts at one time
Your pet's urination is:*
- Normal
- Increased
- Decreased
- Incontinent
- Straining/Vocalizing
The urine appears:*
- Normal
- Clear
- Dark
- Bloody
- Large volumes
- Small volume
Your pet's stools are*
- Normal
- Increased
- Decreased
- Diarrhea
- Blood/mucus in stools
- Incontinent
- Excess Gas
Your pet's skin/feet/nails*
- Dry skin with large flakes
- Dry skin with small flakes
- Brittle Nails
- Dry foot pads
- Itchy skin
When is your pet most itchy?*
- Only sometimes
- During the day
- At night
- All the time
Please describe any coat changes or lesions you have noticed.
Your pet's respiration/breathing
- Normal
- Coughs
- Has had a change in breathing
Describe any changes in breathing.
Has your pet's voice or noises that he/she makes changed at all? If so, please describe
Does the condition inhibit activities? If so, which activities and when?
Does your pet have problems with any of the following? Check all that apply.*
- Slippery Surfaces
- Uneven Surfaces
- Mild Inclines
- Short Walks
- Long Walks
- Stairs
- Posturing for urination
- Posturing for defecation
- Accidents
- Difficulty sitting
- Difficulty standing
- Difficulty rising from sitting
- Difficulty walking
- Limps during walking (Indicate which limb)
- Difficulty running
- Painful or lame following exercise
- Other
When are signs worst?*
- First thing in the morning
- Late in the day
- During activity
- After activity
- After rest
- Same all the time
Activity level prior to injury: (INDICATE ALL THAT APPLY)*
- Leash walk
- Leashed jog/run
- Off leash park/free play
- Activity play (ball, Frisbee, etc.)
- Competitive athlete (i.e. agility, flyball, etc.)
Does your pet seem painful? If yes, please grade (1 = mild to 10 = severe) and when*
Do you see your pet stretch during the day?*
- Yes
- No
Has their stretch changed? Please describe.
ENERGY AND WELL-BEING
How is your pet's energy level in general:*
- Normal
- Reduced
- Increased
When is your pet's energy level the highest?*
- Morning
- Afternoon
- Night
- Consistent
When is your pet's attitude the best:*
- Morning
- Afternoon
- Night
- Consistent
How would you describe your pet's personality*
- Outgoing
- Shy
- Aggressive
- Content
- Restless
- Crabby
- Depressed
Does your pet prefer:*
- To be cool
- To be warm
- No preference
How is your pet's sleep schedule:*
- Normal
- Decreased
- Increased
- Restless at night
- Has frequent dreaming/vocalization/running in sleep
Please describe where your pet sleeps
Has your pet had behavioral changes recently? If so, please describe.
Have you noticed any irritability in your pet? If so, when & why?
Has your pet ever demonstrated aggressive behavior? If so, when & why?
Current medications (please list all prescribed and over the counter medications including dosage and frequency given)
Current dietary supplements & herbal therapies (please list all)
Other medical history (ex: seizures, heart conditions, respiratory conditions, surgeries, etc.)
Does your pet have any past history of cancer? If yes, what type and when diagnosed/how treated?
What specific goals are you seeking for your pet through rehabilitation therapy?
Are you able/willing to do prescribed exercises at home as part of your pet’s rehabilitation therapy
- Yes
- No
Home environment (check all that apply):
- Other animals
- Short flight of stairs
- Primarily carpet in home
- Long flight of stairs
- Primarily tile/hardwood/linoleum in home
- More than 50% of time outdoors in yard each day
- Sleeps on owners bed
- Access to dog door during day
- Jumps onto bed or sofa
- Young children at home
- Free access to house at nigh
- Access to dog door during night
- Small yard
- Large yard
Make my pet a social media star! I authorize and grant dunckel veterinary hospital permission to take a picture of my pet and use it on social media (facebook, instagram).*
- Yes!
- No, thank you
Authorization and Waiver*
Sometimes boarding facilities, groomers, refer ral hospitals, etc. may request records to be faxed. We are asking at this time for your consent to do so if requested.
*
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal . i also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
*
Dunckel Veterinary Hospital has disclosed to me the nature of holistic and complementary therapies and rehabilitative veterinary medicine. I authorize Dunckel Veterinary Hospital to use the recommended rehabilitative and complementary treatments on my pet.
*
I understand that Dunckel Veterinary Hospital recommendations and treatments of my pet constitute no guarantee of results. I further understand that Dunckel Veterinary Hospital recommendations and treatment are based, to some degree, on the information that I supply.
*
In consideration of the foregoing, I waive and release any and all rights, claims, and causes of action I have or may have against Dunckel Veterinary Hospital and its affiliates, officers, directors, employees, representatives, successors and assigns, that may arise as a result of any of Dunckel Veterinary Hospital recommendations or treatment of my pet, including, but not limited to any hydrotherapy, therapeutic exercise, or other treatments or care.
*
I agree that there are inherent risks to me associated with the use of Dunckel Veterinary Hospital facilities arising out of or associated with use and conditions such as wet floors, exercise mats, therapy equipment, and other pets. In consideration for Dunckel Veterinary Hospital granting me permission to use their facilities, I agree to release Dunckel Veterinary Hospital from liability arising out of or associated with such use, and hereafter waive any and all claims which may arise out of or be associated with such permissive use of the facilities.
Owner's Signature
Referring Vet Section
Please attach any advanced diagnostic tests performed.
Drop files here or

Max. file size: 50 MB.
Laboratory results or/and Radiographic findings
Reason for referral (diagnosis, history, physical exam findings, surgical history):
Does this pet have any orthopedic concerns?
- Yes
- No
If there are orthopedic concerns, please specify (Note: if the concern is a cranial cruciate ligament injury please skip to the section below).
Date of injury
Date of diagnosis

MM slash DD slash YYYY
Diagnosed by
Surgery performed
- Yes
- No
Problems following surgery
- Yes
- No
Cranial cruciate ligament injury
- Yes
- No
- Unknown
If yes to previews question, please complete the following section
Stifle affected
- Yes
- No
Date of CCL injury (Leave blank if you do not know)

MM slash DD slash YYYY
Date of diagnosis

MM slash DD slash YYYY
Diagnosed by
Current & recent treatments/medications
CCL Tear type
- Complete
- Partial
- Unknown
Surgery performed
- Yes
- No
If yes, which type of surgery
- TPLO
- TTA
- Tightrope
- Extra-capsular lateral suture
Date of that surgery

MM slash DD slash YYYY
Problems following surgery:
- Yes
- No
Revision or second surgery performed on this stifle?
- Yes
- No
Any history of cancer?
- Yes
- No
Does this pet have any neurologic concerns?
- Yes
- No
Policies

Cancellations, Late Arrivals, and Missed Appointments
- We request that in situations requiring appointment cancellation that we receive at 24 hours notice. This allows us to provide that appointment time to another pet in need.
- Appointments for late arrivals will be shortened to meet the scheduled completion time unless time is available to enable an extension. Appointments arriving more than 10 minutes late may need to be rescheduled to avoid disrupting the appointments of other patients.
- We understand that emergencies arise and appreciate you keeping us informed of unforeseen circumstances.
Financial
- Payment is due in the form of cash, personal check, any of the major credit cards, or by using one of our available financing options (for those who qualify).
- All services purchased and fulfilled are non-refundable. We will be able to refund the price for any unused services due to medical issues or unforeseeable circumstances.
  - Have an electronic signature box
Area affected
Date of injury

MM slash DD slash YYYY
Date of diagnosis:

MM slash DD slash YYYY
Diagnosed by:
Advanced diagnostic tests performed? (MRI CSF, Tap CT, Scan, Musculoskelatal, Ultrasound )
Please attach any advanced diagnostic tests performed.
Drop files here or

Max. file size: 50 MB.
Is urine or fecal incontinence a problem?
- Yes
- No
Surgery performed
- Yes
- No
Was a home exercise plan prescribed?
- Yes
- No
Problems following surgery
- Yes
- No
Do you give consent for us to use photos of your pet(s) for educational purposes?*
- Yes
- No
Additional information or requests
CAPTCHA

Holistic Intake Form

Holistic intake form

Additional Questions

ENERGY AND WELL-BEING

Referring Vet Section

If there are orthopedic concerns, please specify (Note: if the concern is a cranial cruciate ligament injury please skip to the section below).

If yes to previews question, please complete the following section