Canine Consultation Form

Instructions: Copy & paste the form below into notepad, or directly into an email, fill it out in as much detail as possible & email it to me at consultations@dragonflyherbals.com Go back to the Consultation page and send in your payment. I will email a consulation report to you within a few days. I send a lot of information back to my clients, covering changes in eating habits, supplements & herbs, it is helpful to print it & keep it for your reference or for when you go to the health food store to buy supplements. Support by email is always available, if you have questions..

YOUR NAME:

EMAIL: (MAKE SURE YOU ADD MY EMAIL TO YOUR ADDRESS LIST SO MY REPLY DOESN’T GO TO YOUR JUNK MAIL)
PLEASE INDICATE YES, IF YOU AGREE TO THE TERMS OF MY DISCLAIMER:

3. Name of Dog:
Male or Female:
4. Breed of Dog:
5. Age:
6. Spayed or neutered?:
7. Weight, do you feel that your dog is under or over weight?:
8. Health problems at this time:
9. Any previous or recurring health problems:
10. Diet, please list what your dog eats, including snacks, does he like any raw vegetables or fruit?:
11. Is your dog a picky eater?
12. Is your dog always looking for food?
13. Water: do you give tap water or filtered:
14. List any medications that your dog has used now, or in the past.
15. Has your dog used de-worming formulas, and how often:
16. List any herbs or other supplements you dog has used now or in the past:
17. What is your dog’s energy level? (sleeps all the time, very active, etc).
18. Is your dog under stress at home? (just moved, new baby, small children, other new pets, etc.)
19. Is he afraid of other dogs or people, other situations?
20. How many dogs in your household?
21. Other pets?:
22. Does he sleep well?
23. Where does your dog sleep at night?
24. Does he need to go out during the night? How many times?
25. Does he have allergies, skin problems, fleas, or ringworm?
26. Back or joint pain? Where?
27. Vomiting, car sickness, or gas?
28. Constipation or diarrhea?
29. What is your dog’s general mood? (nervous, friendly, etc).
30. Do his eyes have discharge?
31. Is his coat shiny, dull, oily feeling?
32. Is his skin healthy, flaky, dandruff, smells bad?:
33. Are his teeth clean, have tartar, does his breath smell bad?
34. Is his nose hot, dry, runny?
35. Any other questions you have about your dog’s health? (diet, supplements, herbs, flower essences.)

Any information presented here is for informational purposes only and not intended to take the place of diagnosis and treatment by a medical practitioner.