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

Email

Pet Name

Breed of Pet

Birth Date of Pet

Gender of Pet

MaleFemaleN/A

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

HeatColdNo DifferenceN/A

Activity

NormalDecreasedInactiveHyperactiveN/A

Sleep Patterns

RestfulExcessDisturbed/RestlessDreamsN/A

Interactions (People)

NormalAggressiveAvoidanceFearfulN/A

Interactions (Animals)

NormalAggressiveAvoidanceFearfulN/A

VACCINATION HISTORY

Date of Last Vaccination

Which vaccinations?

Vaccination Side Effects?

YesNoN/A

If so, please describe.

Vaccine Titers?

YesNoN/A

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

DERMATOLOGIC CONDITION

Hair/Coat

NormalThinDryOily/GreasyDandruff/FlakingN/A

Duration?

Describe Amount/Area

Skin Condition

NormalDryScalyItchyOtherN/A

Duration?

Describe Amount/Area

Skin Lesions/Sores

YesNoN/A

Location of Lesions (Please describe)

Appearance

RashRednessDiscolorationDischargeN/A

Describe Apprearance (Please describe)

MUSCULOSKELETAL HISTORY

Body Weight

Body Composition

NormalLeanThinOverweightObeseN/A

Muscle Tone

NormalWeakTenseN/A

What Region/Area?

Overall Stiffness

AcuteChronicNoneN/A

Stiffness Worse with:

Dampness‎Heat‎Cold‎N/A

Stiffness Worse upon:

Lying Down‎Exercise‎Overexertion‎N/A

Overall Pain

AcuteChronicNoneN/A

Better with:

MovementRestNothingN/A

Describe Pain

IMMUNE SYSTEM HISTORY

Allergy Type

Allergy Duration

Describe Allergy (Please describe)

Frequent Infections?

YesNoN/A

Location of Infection(s)

Other Comments:

RESPIRATORY HISTORY

Breathing

NormalLaboredShallowCongestedN/A

Couch‎Sneeze‎Wheeze‎Gagging‎N/A

Duration

Frequency

Nasal Discharge

YesNoN/A

Consistency

Amount

Character

Describe Discharge

DIGESTIVE HISTORY

Diet

Since When?

Amount Fed?

Amount Eaten?

Appetite

NormalRavenousDecreasedNoneN/A

Accepts Treats?

YesNoN/A

How often given?

List treats or snacks fed...

Thirst

NormalIncreasedDecreasedN/A

Water Intake

Other Fluid Intake

Describe changes & severity:

BOWEL MOVEMENT

Stool Amount

Frequency

Character

NormalLooseDiarrheaConstipatedN/A

Color

Duration Of Change

Fecal Analysis Results

Vomiting?

YesNoN/A

Frequency

SporadicAfter MealAfter Eating GrassAfter MedsN/A

Frequency

Amount

Appearance

When did it start?

URINARY TRACT HISTORY

Urine Amount

Urine Frequency

Difficulty

NoneStrainingDribblesN/A

Urine Color

Character

ClearCloudyN/A

Urinalysis Results

REPRODUCTIVE SYSTEM

Neutered

YesNoN/A

If so, when?

If not, bred?

YesNoN/A

Successful Litter

YesNoN/A

When?

Genital Discharge?

YesNoN/A

Describe

Other Comments

NERVOUS SYSTEM

Balancing Issues?

StumblesUnsteady on FeetCirclingFalls to Side (left)Falls to Side (right)N/A

Tilt Head

LeftRightN/A

Duration

Progression

Headache?

Avoids LightSquints EyesResists Petting of HeadEating ProblemsN/A

Twitching?

What Part?

Duration

Progression

Seizure?

When?

Severity

Circumstances

Describe

VETERINARY HISTORY

Primary Veterinarian

Referring Veterinary Hospital

Phone

Fax

Previous Records Requested?

YesNoN/A

Sent to Ness Exotic Wellness Center?

YesNoN/A

When Received?

Blood Work?

YesNoN/A

Radiographs?

YesNoN/A

Other Tests