Intake Form (Animal) Name Email Phone number Address Animal's name Animal's breed Animal's date of birth Living arrangement Indoor Outdoor Both Animal's sex Male Female Is the animal spayed or neutered? Yes No Length of time animal has been with you Who is your current veterinarian? Date of last visit? Which vaccines has your animal been given? Please include frequency and date of last vaccination. Type and brand of food Current medications and supplements. (Including flea/tick/heartworm, other parasite medications.) Exercise program (how is your animal exercised and how often.) Please list the people in your family that your animal socializes with. Other people your animal frequently socializes with (friends, trainers, sitters, etc.) Other animals in your family. Please include names, type/breed and how long in the family. Health history Presenting issues/concerns (physical, emotional, behavioral, etc.) Please include intensity on a scale of 1-10 (10 is most intense) and how long the problem has been present. Any unique circumstances or transitions in your animal's life when the problem(s) first presented? Have you tried to resolve these issues through other means? (please describe) How would you characterize your animal's energy level? How would you characterize your animal's appetite? How would you characterize your animal's anxiety/stress level? How would you characterize the quality of your animal's skin and coat? How would you characterize your animal's condition and quality of urination and bowel movements? How is your animal with unfamiliar people or animals? Has your animal bitten a person or animal and broken their skin? Are there any places on the animal's body that your animal guards, has sensitivity to or does not like touched? Is there anything else you would like me to know about your animal? How did you hear about BodyTalk California? Please enter the following code to prove you're human: