Evaluation Purely Pets

• Please read the directions before beginning the evaluation:

  In order to give the best suggestions for your pet, please complete this evaluation. This is very important in order to help you find what your pet needs. The evaluation is a little lengthy, but many questions can be answered with a yes or no answer.

• APPOINTMENT INFORMATION

• Desired Date Date Format: MM slash DD slash YYYY
• Desired Time : HH MM AM PM
• Desired Date Date Format: MM slash DD slash YYYY
• Desired Time : HH MM AM PM
• Desired Date Date Format: MM slash DD slash YYYY
• Desired Time : HH MM AM PM

• GENERAL INFORMATION

• Owner’s name and phone number*
• Your pet's name
• Breed
  • Dog
  • Cat
• Age
• How much does your pet weight?— Select —Is your pet underweight?Is your pet overweight?Is your pet hyperactive?Is energy level excellent, good, fair or poor?
• Sex
  • Male
  • Female
• Spayed or neutered

• GENERAL HEALTH

• Describe the symptoms your pet is suffering from?
• Is there unusual panting to signal distress or pain?
• Any other major illnesses/surgeries in the pet's lifetime?
• What is the Veterinarian's diagnosis?
• What medications is your pet taking? How long?
• Since taking medication, has there been any improvement?
• What supplements/herbs/homeopathic is your pet taking? Please give brand names and any websites for the products.
• Since taking these supplements has there been any improvement?
• Is your pet suffering from any of the following symptoms? If so, which ones? If none, put NO after each symptom or ailment.
• Food Allergies
• Food Sensitivities
• Diabetes
• Constipation
• White-Coated Tongue
• Brittle Nails
• Rectal Itching
• Irritable Bowel Syndrome
• Asthma
• Chronic Infections
• Mucus in the Stool
• Clogged Sinuses
• Environmental Sensitivity
• Hypothyroidism
• Cancer
• Cushing's Disease
• Addison's Disease
• Arthritis
• Hip Dysplasia
• Poor Wound Healing
• Heart Problems
• Does your pet suffer from seizures?— Select —If so, please describe the symptoms before, during and after the seizures.Is there a pattern to the seizures? Meaning, do they mostly occur during the day, during stressful times, only at night, etc.?If you keep a seizure journal which includes days and times of seizures, please email that with the evaluation. You can scan and email it.

• NUTRITION

• What are you feeding (wet/dry, table, raw)? Please list brand names.
• How often do you feed?
• Do you give any treats? If so, what?
• Has the pet's diet changed recently?
• Appetite level? Have eating habits recently changed?
• Do you use filtered water or tap? Are you treating the pet's water with anything?

• DIGESTION

• Does the pet have daily bowel movements? How many?
• Is gas a problem?
• Has the stool odor, volume, color, or consistency changed recently?
• Any diarrhea/constipation?
• Any mucous in the stool?
• Is there any straining when having a bowel movement?
• Do you visibly see worms in the stools?

• URINATION

• Has the pet's daily intake of water changed?
• Is it painful for your pet to urinate?
• Any blood in urine? Is there any unusual odor to it (sweet or metallic)?
• Any problems with incontinence?
• Frequent or reoccurring bladder or kidney infections?
• If you own a cat, do you use clumping litter?
• Any blood in the stool?

• SKIN AND COAT CONDITION

• Have there been any changes in general condition?
• Any dry flakes, dull or greasy coat, hot spots or pimples?
• Excessive shedding, hair loss, scratching or licking, fur pulling, etc.?
• Is there a foul odor to the skin?
• Thinning hair?
• Shiny coat?
• Mange?
• How often do you bathe your pet?
• If you do bathe your pet, what is the brand name of the shampoo?
• Is your pet susceptible to fleas or ticks?
• Is your pet susceptible to intestinal worms?

• EARS

• Any visible signs of mites (dark specks like pepper) or infection?
• Do the ears smell?
• Are symptoms related to allergy seasons or weather changes?
• Is there any discharge coming from the ears?
• Reddened area inside the ears?
• If your pet is having problems with the ears, what are you currently using?
• Any blood in the ears?
• Have you ever been told by your vet that you pet has a yeast or bacteria infection in their ears?

• EYES AND NOSE

• Discharge from the eyes, or nose?
• Any swelling or redness in either?
• Blocked tear ducts?
• Are the eyes cloudy?
• Rapidly failing vision?
• Cataracts?

• MOUTH

• Bad breath?
• Tartar on teeth?
• Bleeding or infected gums?

• NERVOUS SYSTEM, BODY, JOINTS, & MUSCLES

• Has pet shown any signs of confusion, lethargy, or uncontrollable shaking?
• Any rapid weight changes?
• Fever or body odor present?
• Has their movement, especially getting up or down changed?
• Noticeable pain or limping?
• Restless sleep or exhaustion?

• RESPIRATORY & CARDIAC

• Has the pet's breathing changed?
• Is there any cough or wheezing?

• EMOTIONAL OR BEHAVIORAL

• Has the pet recently become withdrawn, fearful, nervous or aggressive?
• Have they become more destructive in chewing on themselves, furniture, walls, or suddenly soiling in the house?
• Any environmental changes — recent moves, death in family, divorce, animal death, new animals, new addition to the family, etc.?

• ENVIRONMENT

• Have you recently sprayed the yard for weeds or applied chemical pest control solutions in the house, yard, or even on the pet?
• Is the pet wearing a chemically based flea/tick collar or been treated with a flea control such as Frontline or Advantage?
• Any vaccinations in last 3-4 months? Any immediate reactions?
• Are they any other poisons, radiator fluid, antifreeze, or toxic plants, such as poinsettias, that the pet may have access to chewing on or ingesting?
• Have you installed new floor covering? New Paint?
• Do you give a heartworm pill each month? If so, what brand do you give?

• BLOODWORK

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