Animal Health and Well-Being History Form

Please answer the following questions honestly and to the best of your ability

Date

Name

Phone

E-mail

Country

Address

How did you hear about me?

Animal Name

Species

Breed

Sex

Age

Has The Animal been Sterilized (Spayed/Neutered)?

Yes No

Living Environment

Indoor Outdoor Both

Length of Time Animal has been with You?

Who is Your Current Veterinarian?

Date of Last Vet Visit?

Vaccination Program

Frequency (Yearly?)

Date of Last Vaccination

Current Medications/Supplements (Including Flea/Tic/Heartworm, Other Parasite Medication)

Type / Brand of Food? Any Concerns Around Meal Time?

Excercise Program

Animal Family / Group Make Up

Other People Your Animal Frequently Socializes With

Other Animals in Your Family

Type/Breed of Animals

How Long in the Family?

Health History

Presenting Issues/Concerns 1

Intensity on Scale 1-10

Presenting Issues/Concerns 2

Intensity on Scale 1-10

Presenting Issues/Concerns 3

Intensity on Scale 1-10

Presenting Issues/Concerns 4

Intensity on Scale 1-10

Presenting Issues/Concerns 5

Intensity on Scale 1-10

How long have these issues presented?

Were there any unique circumstances or transitions occurring in your animal's life when problems first presented? If so, please explain

Have you tried to resolve these issues through other means? If so, please explain:

Energy Level

Appetite

Condition and Regularity of Bowl Movements

Anxiety/Stress Level

Quality/Condition of Skin/Coat

What is the typical demeanor of your animal?

How is your animal with unfamiliar people?

How is your animal with other animals?

Any places on body your animal guards/has sensitivity/does not like touched?

Anything else you would like me to know?

I (Owner)

Understand that the BodyTalk session provided by this Certified BodyTalk Practitioner for my animal

is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may be creating pain, discomfort or disease for my animal. BodyTalk is non-invasive, safe and objective. It utilises the body's own innate intelligence to reestablish communication within itself. I understand that BodyTalk is not a substitute for veterinary care or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the the Practitioner prescribe medications. I understand the BodyTalk Practitioner strongly recommends immediate veterinarian attention for any physically based conditions with my animal. I understand that the safety and care of my animal is ultimately my responsibility.

I agree to pay a fee per session. Payment is due at time of service*. Since time has been especially reserved for me, I understand that a 24-hour cancellation is required to avoid charges for my scheduled session. If I have any questions or concerns, I will address these promptly with the BodyTalk Practitioner. I hereby authorise the Certified BodyTalk Practitioner to provide my animal with BodyTalk sessions.

*Individual Practitioner prices and offerings may vary.

DATE

Please give consent here by ticking this box

I agree reimbursement or payment is due at time of service as time has been especially reserved for me.