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.
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Email address
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Your email
Your First and Last Name
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Your answer
Your Mailing Address
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Your answer
Your Phone Number (Please indicate if NOT a cell number)
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Your answer
Animal's Name
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Your answer
Date of Birth (or approximate age)
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Your answer
How old was your pet when you got him/her?
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Your answer
Breed and Color
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Your answer
Gender
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Female
Male
Spayed or Neutered
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Yes
No
WHEN was the last set of vaccines? Which vaccines did s/he receive?
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Your answer
What supplements or medication is your pet on (including Heartworm and Flea/Tick prevention)?
Your answer
What are you currently feeding your pet?
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Your answer
What is your MAIN COMPLAINT at this time? Please be specific and detailed.
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Your answer
When did this complaint start?
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Your answer
What was going on the pet’s life around the time this complaint started that might explain it.
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Your answer
Does the above concern get better with exercise? or with rest?
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Your answer
What is the worst part of your pet’s day/night? What happens at that time?
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Your answer
Is the above concern affected by weather in any way? Are the symptoms better or worse in certain types of weather?
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Your answer
Describe your pet’s drinking habits: Prefers cold water over warm water? Gulps water? Drinks infrequently/Drinks often/ Is obsessed with water
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Your answer
Describe your pet's feeding habits.
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Your answer
Any digestive complaints? Please explain
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Your answer
Any changes in bowel habits? Are the stools always well formed? Have you noticed anything unusual about the stool lately?
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Your answer
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.
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Your answer
What ameliorates (soothes) your pet’s complaints? What makes him feel better? Consider the examples above.
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Your answer
Does your pet prefer to be outside in the snow or the sun?
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Your answer
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?
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Your answer
Does your pet prefer to lie in the sun or the shade?
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Your answer
Any fears that you can think of? Thunder? other dogs? horses? kids? etc
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Your answer
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.
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Your answer
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?
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Your answer
Any ear problems in the past or present? How was the problem resolved?
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Your answer
What’s his or her home-life like?
Your answer
What’s his or her reaction to the following: Consolation, Scolding, Noise, Surrounding Activity, Other Dogs/Cats
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Your answer
Does he or she like to be around people or happier alone?
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Your answer
What fears does he/she have?
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Your answer
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.?
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Your answer
How does your pet react to a new person entering the home?
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Your answer
How does he/she react to you or other family members entering the home?
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Your answer
How does he/she react to new situations with new people or new situations with new animals?
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Your answer
Does he/she show anger or hurt if you’ve been away for a long time? How?
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Your answer
Any recent personality changes?
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Your answer
Where does your pet like to sleep?
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Your answer
In what position does he or she sleep?
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Your answer
Is there anything peculiar or striking about your animal’s behavior or symptoms?
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Your answer
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.
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Your answer
List 3-5 words (adjectives) to describe your pet
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Your answer
Send me a copy of my responses.
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