Comprehensive Consultation Intake

Comprehensive History Questionnaire

"*" indicates required fields

So that Dr. Kangas may best prepare for your comprehensive consultation, please complete and submit the information below. Notes: All questions require a response, if the answer is no or none, please simply type NONE or N/A in the prompt. Average time to complete is 5-10 minutes. Please be sure to have a photo of your pet available to upload.

Your Name*

First Last

Spouse/Partner/Significant Other (that you would like on record)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Phone*

Your Email*

Your Pet's Name*

Species*

Canine

Feline

Breed*

Pet Coloring*

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Please enter your pet's birth date or approximate age*

Presenting Concern

What are your primary concerns for your pet?*

What are your goals working with Dr. Kangas*

Why did you decide to seek Holistic Care?*

History

How long have you had this pet?*

Where did you acquire your pet?*

What other pets are in your household? Do they get along?*

Describe your pets' personality type/behavior?*

Medical

Please provide clinic name and phone number of Veterinarian(s) - General Practice/Specialist your pet has seen in the past 12 months*

Please list all current and past health problems of your pet, approximate dates of symptoms and severity. Please include any treatments that were done; conventional (surgery, antibioics, steroids) or holistic (acupuncture, chiropractic, herbs, supplements)*

Do you use Heartworm Prevention?*

if yes, which product(s)

Do you use Flea/Tick Prevention?*

if yes, which product(s)

Does your pet currently take any prescribed medications? Please List*

Does your pet currently take any supplements? Please List*

Has your pet received any vaccines in the past 3 years?*

if yes, please list vaccine and date given

Diet & Environment

What specifically does your pet eat?*

How long have you been feeding this diet?*

How many meals per day does your pet eat?*

Amount of food given at each meal?*

What kind of treats do you give your pet? How often?*

What type of water do you offer your pet?*

Any known dietary sensitivities or food allergies?*

Does your pet have any unusual cravings?*

Has there been any major changes in the pet's household environment (moving, marriage, death of other pet or human, divorce, new pet)?*

Behavior

Is your pet fearful or aggressive? If yes, in what situation(s)?*

How does your pet react in new situations? With new people? Does your pet have any anxieties?*

Does your pet display an obvious temperature preference?*

How often is your pet bathed or groomed?*

Exercise

Describe your pets' activity level and how often he/she gets exercise.*

Other

Does anyone in the household receive any holistic medical treatment?*

Please submit a photo of your pet*

Max. file size: 256 MB.

ensure a clear face view

Whom may we thank for referring you?*

Please select your preferred method of communication for appointment reminders*

Text Message

Call Me

We like to share our patients on social media. Do you consent to allow us to post images of your pet to our social media, including but not limited to Facebook, Instagram and our website?*

Yes

PLEASE READ AND SIGN BELOW:

I authorize Integrative Veterinary Care practitioners to treat my pet: (Please sign or initial below)

Signature

Entry Date*