New Client Integrative Consultation Form in Evergreen Park, IL

Please complete this questionnaire BEFORE arriving for your initial appointment. Please bring all supplements with you on your visit if your pet is scheduled for Nutritional Response Testing. Please bring a sample of the food(s) and treats you are currently feeding your pet.

Name*
First Last
Your Pet's Name*
Type of Pet*
Briefly describe your pet’s current primary medical problem(s) or the reason for today’s visit. Please note when the problem(s) first started.
What medications, supplements or treatment modalities have been used to treat this problem? Have any of these treatments helped? Did any of them make the condition worse? Please list the medications and supplements, including the doses, that you are currently giving.
Are there any other chronic (long term) conditions your pet has that we need to know about?
Does your pet eat rocks, sticks, grass, strange things? Please explain.
Has your pet ever had abnormal blood test results? Please explain.
Does your pet have any strange behaviors? Please explain.
Any regular episodes of diarrhea, vomiting, anorexia, constipation?
Whom may we thank for referring you and if your pet is under the care of another vet, please list the doctor and hospital’s name and the date of the last visit
Has your pet had any adverse reactions to medications, vaccines, supplements or foods?
List all foods and treats that your pet eats and has access to daily (include amounts and brand names).
Any past accidents or injuries? List any possible scars and/or surgery sites.
What are your goals for this visit and do you have specific questions you’d like answered?
Where has your pet lived or traveled to in his/her lifetime?
If your pet has had chiropractic in the past, when was the last treatment done? Was it helpful?
Does your pet prefer hot or cold temperatures? If a preference, please explain.
Does your pet sleep soundly through the night? If not please explain.