Phone *
Email *
Pet's Name *
If Other, please specify
Breed
Color
Age
Weight
If health problem(s), please describe below
What diagnostics have been performed and what were the results? (x-rays, bloodwork, etc..)
What treatments were utilized (ex. surgery, physical therapy)
Did the pet show any improvement? If so, please describe:
Current Medications: *
Current Herbs and/or Supplements: *
Current Diet:
Current Exercise Regimen:
If yes, please identify all that apply (front right leg, front left leg, back right leg, back left leg)
Is the pain in a specific area? If yes, where?
How does the weather/temperature affect your pet's pain?
If other, please specify:
If other, please specify:
If other, please specify:
If other, please specify:
If other, please specify:
Describe any reproduction problems your pet has had:
Describe your pet's change in breathing:
If other, please specify:
Describe your pet's change in noise/voice:
If other, please specify:
If your pet could have any human job or career, what would it be?
Is there anything else we should know about your pet's health or emotional history?