Holistic Questionnaire

    Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear
    client profile, we need you to fill out our Holistic Questionnaire below. Your data is safe with us.

    Today's date

    First Name

    Last Name

    Email

    Pet Name

    Breed of Pet

    Birth Date of Pet

    Gender of Pet

    Presenting Complaint

    Diagnosis

    Date of Onset

    Progression

    Current Medications (Please include dose and duration)

    Current Supplements (Please include dose and duration.)

    GENERAL BEHAVIOR

    Seeks/Preference

    Activity

    Sleep Patterns

    Interactions (People)

    Interactions (Animals)

    VACCINATION HISTORY

    Date of Last Vaccination

    Which vaccinations?

    Vaccination Side Effects?

    If so, please describe.

    Vaccine Titers?

    Titers Details (Please describe which ones, when and the results.)

    DERMATOLOGIC CONDITION

    Hair/Coat

    Duration?

    Describe Amount/Area

    Skin Condition

    Duration?

    Describe Amount/Area

    Skin Lesions/Sores

    Location of Lesions (Please describe)

    Appearance

    Describe Apprearance (Please describe)

    MUSCULOSKELETAL HISTORY

    Body Weight

    Body Composition

    Muscle Tone

    What Region/Area?

    Overall Stiffness

    Stiffness Worse with:

    Stiffness Worse upon:

    Overall Pain

    Better with:

    Describe Pain

    IMMUNE SYSTEM HISTORY

    Allergy Type

    Allergy Duration

    Describe Allergy (Please describe)

    Frequent Infections?

    Location of Infection(s)

    Other Comments:

    RESPIRATORY HISTORY

    Breathing

    Duration

    Frequency

    Nasal Discharge

    Consistency

    Amount

    Character

    Describe Discharge

    DIGESTIVE HISTORY

    Diet

    Since When?

    Amount Fed?

    Amount Eaten?

    Appetite

    Accepts Treats?

    How often given?

    List treats or snacks fed...

    Thirst

    Water Intake

    Other Fluid Intake

    Describe changes & severity:

    BOWEL MOVEMENT

    Stool Amount

    Frequency

    Character

    Color

    Duration Of Change

    Fecal Analysis Results

    Vomiting?

    Frequency

    Frequency

    Amount

    Appearance

    When did it start?

    URINARY TRACT HISTORY

    Urine Amount

    Urine Frequency

    Difficulty

    Urine Color

    Character

    Urinalysis Results

    REPRODUCTIVE SYSTEM

    Neutered

    If so, when?

    If not, bred?

    Successful Litter

    When?

    Genital Discharge?

    Describe

    Other Comments

    NERVOUS SYSTEM

    Balancing Issues?

    Tilt Head

    Duration

    Progression

    Headache?

    Twitching?

    What Part?

    Duration

    Progression

    Seizure?

    When?

    Severity

    Circumstances

    Describe

    VETERINARY HISTORY

    Primary Veterinarian

    Referring Veterinary Hospital

    Phone

    Fax

    Previous Records Requested?

    Sent to Ness Exotic Wellness Center?

    When Received?

    Blood Work?

    Radiographs?

    Other Tests