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

    Birth Date of Pet

    Gender of Pet

    Date of Onset

    Current Medications

    Current Supplements:

    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:

    DERMATOLOGIC CONDITION

    Hair/Coat

    Describe Amount/Area

    Skin Condition

    Describe Amount/Area

    Skin Lesions/Sores

    Location of Lesions

    Appearance

    Describe Apprearance

    MUSCULOSKELETAL HISTORY

    Body Composition

    Muscle Tone

    Overall Stiffness

    Stiffness Worse with:

    Stiffness Worse upon:

    Overall Pain

    Better with:

    IMMUNE SYSTEM HISTORY

    Describe Allergy:

    Frequent Infections?

    Other Comments:

    RESPIRATORY HISTORY

    Breathing

    Nasal Discharge

    DIGESTIVE HISTORY

    Appetite

    Accepts Treats?

    List treats or snacks fed...

    Thirst

    Describe changes & severity:

    BOWEL MOVEMENT

    Character

    Vomiting?

    Frequency

    When did it start?

    URINARY TRACT HISTORY

    Difficulty

    Character

    Urinalysis Results

    REPRODUCTIVE SYSTEM

    Neutered

    If not, bred?

    Successful Litter

    When?

    Genital Discharge?

    Other Comments

    NERVOUS SYSTEM

    Balancing Issues?

    Tilt Head

    Headache?

    Twitching?

    Seizure?

    VETERINARY HISTORY

    Previous Records Requested?

    Sent to Ness Exotic Wellness Center?

    When Received?

    Blood Work?

    Radiographs?