Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved
Cat AND DOG
Health History Consultation Form
Complementary Therapeutics NZ Limited,
C/O Rex Dance,
Rydal Street,
Hoon Hay, Christchurch 8025.
Phone: 0276471294
Your name: _________________________________________ Date: _______________________________
Email address: ______________________________________ Phone #:_____________________________
Mobile Phone #: _______________________________________________
Postal address:
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In order to make the most appropriate recommendations, it is important that I know as much as possible about
your pet. Please complete the following questionnaire – use extra pages if needed. If possible attach a
resent photo of your pet and any visible skin/skeletal problems.
Name of pet: ________________________________________ Dog or Cat? __________________________
Breed: _________________________________ Gender M/F? _______ Age: _______ Weight: ___________
If this is a mixed breed please describe, including its weight and height: ______________________________
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Where did you obtain your pet (i.e. shelter, rescue group, breeder etc)? ______________________________
What age was your pet when they came to live with you? _________________________________________
If from a breeder, do you have health certificate copies from your pet's parents? _______________________
Is your pet spayed, neutered or intact? ________________ Age that spay/neuter was done? _____________
Was there any physical or emotional change in your pet after being spayed or neutered? (If yes, please
explain):
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Has your pet ever been pregnant (Y/N)? _________ If yes, please list how many litters and the approx. dates:
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Is your pet micro-chipped? (Y/N)? __________ When did the microchip get implanted? __________________
Date of last vaccinations: _________________ Was vaccinated for: _________________________________
How often is your pet vaccinated and which vaccines do they receive? _______________________________
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General health condition (skin and coat condition? eye/ears - any discharge? normal or loose stools?
lethargic/energetic? teeth, gum and mouth condition? etc.)
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Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved
Has the animal been diagnosed by a veterinarian with any illness or health problems (arthritis, skin problems,
kidney disease, hip dysplasia, injuries, etc.)? Please list all diagnoses and how long problems have been
going on, as well as any current symptoms: _____________________________________________________
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What surgery (if any) has your pet had (include dates)?
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Is your pet currently on any medications? (Describe what each medication was prescribed for and how long
he/she has been on them):
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Has your pet ever taken a course of antibiotics? (List each occurrence, reason & name of antibiotic if known):
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What tests (if any) has your pet had (x-rays, blood, urine, etc.)? What were the results of these tests?
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Has he/she had any chiropractic, acupuncture, laser or similar treatment? If so, describe
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Is your pet currently on any parasite prevention drugs? (Frontline, Advantage, Ivermectin, etc):
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Does your pet exhibit any of the following physical conditions (please explain for any yes answers)
 Allergies
 Ear problems - Infections/Mites
 Arthritis/Joint Stiffness
 Eye problems - Infections /discharge
 Autoimmune Disorders
 Heart problems
 Cancer / Tumours
 Reproductive problems
 Cataracts / Vision problems
 Seizures
 Deafness / Hearing impaired
 Skin / Coat problems
 Digestive problems
 Skeletal abnormalities (hip dysplasia etc.)
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Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved
Other - please explain:
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Does your pet exhibit any of the following temperament problems? (Please explain any yes answer)
 Aggressive behaviour
 Dominance Issues
 Barking (excessive)
 Doesn't get along with others
 Biting
 Fearful / Anxiety
 Chewing / licking objects
 Pacing
 Chewing / licking self
 Scratching
 Compulsive behaviour (explain below)
 Separation Anxiety
Other - please explain: _____________________________________________________________________
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If you know the parents, brothers, sisters and other relatives of your pet, are there known health problems in
those bloodlines (kidney disease, heart disease, epilepsy, hip dysplasia, etc.)?
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Describe the animal's current lifestyle. How much exercise, how much time is spent outdoors/indoors,
how much time is spent alone, sleeping location, interactions with other pets/people, favourite toy, favourite
activity & any other pertinent info. Please be as detailed as possible: _________________________________
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Current diet - please include as much info as possible - name of food, amount given each day, how long
he/she has been eating this food and what food was he/she eating before this current diet and is he/she
drinking town water?
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How many times have you switched foods? and what brands have been used?
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List ALL supplements, vitamins, and any treats or table scraps this animal gets & how often: ______________
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Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved
What brand of laundry soap, floor & counter cleaners do you use? ___________________________________
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Do you use air fresheners or burn scented candles?
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What other cleaning products do you use in your home? (For toilets, floors, furniture, wood, glass etc.):
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What products do you use in your yard? Any pesticides, herbicides or chemical fertilizers? ________________
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Any recent renovations in the home that included painting or new flooring? ____________________________
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Does your pet have any allergies/sensitivities that you know of (food, chemicals, plants, etc.)? If so, to what
substances and how do these affect him/her?
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Any recent stressful events (moving, change in schedule or amount of time spent at home, etc) that have
coincided with an occurrence or worsening of the animals symptoms/behaviours? ______________________
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What are your three main concerns for your pet?
1) _________________________________________________________________________________
2) _________________________________________________________________________________
3) _________________________________________________________________________________
How did you find my service? ________________________________________________________________
CLIENT CONSENT
I, __________________________________, GIVE CONSENT FOR MY PETS HEALTH INFORMATION TO BE
DOCUMENTED AND APPROPRIATE PHYSICAL EXAMINATIONS AND ASSESSMENTS TO BE PERFORMED AS
REQUIRED. I UNDERSTAND THAT FOLLOWING THE CONSULTATION A TREATMENT PLAN WILL BE CREATED
FOR MY PET AFTER AGREEMENT BETWEEN MYSELF AND THE PRACTITIONER. I WILL GIVE THE
PRACTITIONER ALL PERSONAL INFORMATION ABOUT THE PET NEEDED TO PERFORM A SAFE AND
SUCCESSFUL TREATMENT.
I AM AWARE THAT BOTH PRACTITIONER AND I HAVE THE RIGHT TO STOP THE CONSULTATION PROCEDURE
AND / OR TREATMENT AT ANY TIME. *Recommendations, including supplements, are intended as a
complement to veterinary care and are not a substitute for veterinary diagnosis and treatment*.
CLIENT SIGNATURE:________________________________________________
PRACTITIONER SIGNATURE:_________________________________________________
Rex Dance, Medical Herbalist and Homeobotanical Therapist.
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