Supplemental History & Treatment Expectation Questionnaire

Name: *

First

Last

Email: *

How Old Is Your Pet? *

What Medications Is Your Pet Currently Taking? *

What Diet Is Your Pet Currently Eating? *

Diet Frequency? *

Diet Amount? *

Diet Duration? *

What Diets Has Your Pet Eaten In The Past? *

What Treats And Supplements Has / Is Your Pet Taken? *

What Is Your Pet's Exercise Routine? *

What Medical Condition/s Does Your Pet Have? *

Condition Duration: *

Condition Frequency: *

List All Symptoms Your Pet Has That Need To Be Improved By Treatment? *

Have Any Of These Symptoms Been Relieved Longer Than 3 Months By Any Past Treatment? *

What Outcome Would Be A Satisfactory Resolution Of The Above Listed Symptoms? *

Is There Any Treatment, Diagnostic Testing, Ingredients, Or Therapy You Are Displeased With Or Will Not Accept If Offered / Suggested? *

How Likely Are You To Stick To A Strict Management Plan For Your Pet? *

Will You Consider Referral For Further Treatment And Care? Chemotherapy? Diagnostics? *

What Amount Of Time And Money Have You Budgeted For Care Of Your Pet For These Symptoms? *

What Would You Prefer To Do If Complete Resolution Cannot Be Achieved For Your Pet's Symptoms? *