Homeopathic Intake
Homeopathic Intake Form for Dr. Heike Jung, DVM (Beyond Vet Med)

This intake is critical in finding the right remedy for your pet. Please be as descriptive as you can be. Keep this link in a safe place so you can access it anytime you think of more information.
The more descriptive you can be, the easier it will be for me to find a remedy that matches your individual pet or equine partner.
Email address *
Your First and Last Name *
Your Mailing Address *
Your Phone Number (Please indicate if NOT a cell number) *
Animal's Name *
Date of Birth (or approximate age) *
How old was your pet when you got him/her? *
Breed and Color *
Gender *
Spayed or Neutered *
WHEN was the last set of vaccines? Which vaccines did s/he receive? *
What supplements or medication is your pet on (including Heartworm and Flea/Tick prevention)?
What are you currently feeding your pet? *
What is your MAIN COMPLAINT at this time? Please be specific and detailed. *
When did this complaint start? *
What was going on the pet’s life around the time this complaint started that might explain it. *
Does the above concern get better with exercise? or with rest? *
What is the worst part of your pet’s day/night? What happens at that time? *
Is the above concern affected by weather in any way? Are the symptoms better or worse in certain types of weather? *
Describe your pet’s drinking habits: Prefers cold water over warm water? Gulps water? Drinks infrequently/Drinks often/ Is obsessed with water *
Describe your pet's feeding habits. *
Any digestive complaints? Please explain *
Any changes in bowel habits? Are the stools always well formed? Have you noticed anything unusual about the stool lately? *
What aggravates your pet’s complaint or what aggravates your pet in general? Think about food, weather, exercise/movement, rest, sleep, eating, noise, heat or cold, company, sympathy, touching, pressure, presence of strangers, being approached, or anything else you can think of. *
What ameliorates (soothes) your pet’s complaints? What makes him feel better? Consider the examples above. *
Does your pet prefer to be outside in the snow or the sun? *
Is your pet a couch potato or quite active? Would s/he prefer to stay in the house and snuggle in bed or go for walks? *
Does your pet prefer to lie in the sun or the shade? *
Any fears that you can think of? Thunder? other dogs? horses? kids? etc *
Describe your pet’s personality. People friendly? Pet friendly? Playful? Moody? Introverted? Extroverted? Likes to sleep in? Is a night owl? Prefers to go for walks in the mornings or at night? ANYTHING that would describe your pet's personality will be very helpful. *
Any skin problems in the past or present? Please explain (this includes hives, warts, tumors, changes in skin texture, etc). How was the problem resolved in the past? *
Any ear problems in the past or present? How was the problem resolved? *
What’s his or her home-life like?
What’s his or her reaction to the following: Consolation, Scolding, Noise, Surrounding Activity, Other Dogs/Cats *
Does he or she like to be around people or happier alone? *
What fears does he/she have? *
Describe his or her nature? Is he/she dominant, submissive, aggressive, shy, noisy, quiet, excitable, docile, impulsive, steady, careful, clumsy, gentle, rough, obedient, disobedient, etc.? *
How does your pet react to a new person entering the home? *
How does he/she react to you or other family members entering the home? *
How does he/she react to new situations with new people or new situations with new animals? *
Does he/she show anger or hurt if you’ve been away for a long time? How? *
Any recent personality changes? *
Where does your pet like to sleep? *
In what position does he or she sleep? *
Is there anything peculiar or striking about your animal’s behavior or symptoms? *
Give a time-line of medical and important events in your pet’s life that may have left a mark on him or her, mentioning his or her age at the time and how he/she coped with them. *
List 3-5 words (adjectives) to describe your pet *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy