Animal Bodywork Intake Form

The practitioner reserves the right to contact your veterinarian with any questions about your animal(s).

Guardian First Name

Guardian Last Name

Phone

Veterinarian Name

How long have you had your animal?

Where did you get your animal from?

What are your goals and objectives?

How did you hear about us?

Health History Intake

Species

Canine

Equine

Other

Animal's Name

Breed

Approximate Date of Birth

Month

Day

Year

Color

Approximate Weight

Does your animal compete in competitions, have a job, or have an exercise routine? (ex. agility, herding, service work, jogs, fetch, etc.)

What do you feed your animal?

What supplements is your animal on?

How is your animal's appetite?

Decreased

Normal

Increased

Has your animal's stools changed? If so, please explain:

Has there been any changes in your animals coat? If so, please explain:

Has your animal had any surgeries? If so, please explain:

Has your animal had any x-rays, CT scans, or MRI? If so, please explain:

Does your animal have any illnesses or has had any illnesses that can cause long term issues? If so, please explain:

Does your animal have any injuries or has had any injuries? If so, please explain:

Does your animal have any orthopedic or joint issues? If so, please explain

Is your animal on a pain management protocol? If so, please explain any therapies and medications:

Is your animal on any other medications for anything else? If so, please explain:

Has there been any changes in your animals environment (changes in living arrangements, new animals, new people, changes in diet, etc)? If so, please explain:

Please look in your email for our reply (also check your spam folder). It is easier to get your animal set up for their first session this way. Also, we ask for at least 1-2 business days for our reply. We appreciate your patience!