Integrative Exam Intake Form INTEGRATIVE EXAM INTAKE FORMPet Name Client Name Date Eyes / Ears1. Do you have any concerns about Your pet's eyes or ears? 2. Has your pet ever had any ear infections? 3. Any redness, discharge or squinting of their eyes? 4. Have you noticed any vision or hearing changes? Mouth / Teeth1. Has your pet ever had a dental procedure/teeth cleaning? 2. Have you noticed any odor, difficulty chewing or excessive drooling? 3. Do you brush their teeth? How often and with what? 4. What types of chews does your pet use? Nose / Lungs1. Have you noticed any sneezing or nasal discharge? 2. Has your pet had labored or irregular breathing? 3. Have you noticed any coughing/hacking? Digestive Tract / Diet1. What diet is your pet on? Amounts and time of feeding? 2. What treats do you give? How often? 3. Any vomiting now or in the past? What and how often? 4. Any stool changes or diarrhea now or in the past? 5. Do you notice any gas or gurgling abdomen? Skin / Hair coat1. Have you noticed any hair coat changes/loss, etc.? 2. Is or has your pet been itchy? Skin lesions? 3. Any lumps or bumps? 4. What flea preventative do you use and how often? 5. Do you trim your pet’s nails? How often? Exercise / Mobility1. What sort of exercise does your pet receive and how often? 2. Any limping, stiffness, reluctance to jump or other mobility concerns? 3. Any area of the body that your pet seems sensitive to touch? 4. Does your pet ever seem painful? Environment / Emotional1. Do you have other pets in the home? Names and ages? 2. Do they all get along? 3. Where does your pet stay during the day and sleep at night? 4. Does everyone in the household love your pet as much as you? 5. Do you use any chemicals in the house or yard? 6. Are there any stressors in your pet’s life? 7. How would you describe your pet’s personality? Major Health History1. Please list any major injuries or illnesses: 2. Please list any vaccine reactions or unwanted medication side effects: 3. When was your pet’s last blood work performed? Health Goals1. What are your primary concerns for your pet? 2. What are your goals for your pet’s health? 3. Any other concerns or questions for today? *Please bring all supplements or medications that your pet is currently receiving to your appointment* ***Please bring a picture or name and ingredient list of your pet’s diet and treats****Please bring all supplements or medications that your pet is currently receiving to your appointment* ***Please bring a picture or name and ingredient list of your pet’s diet and treats***
