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Animal Intake Form

Welcome to Mend Well Health’s Intake Form! We’re grateful you’ve chosen us to support your animal companion on the path to better health. Please fill out the following questions as thoroughly as possible, so we can gain a clear understanding of your animal's unique needs and tailor our care to best serve them. Thank you for entrusting us with your well-being—we look forward to working together on your journey.

Animal Information

Species
Dog
Cat
Horse
Other
Sex
Male
Female
Single choice
Neutered/Spayed
Intact

Owner Information

Follow-Up Preferences

How would you prefer to be contacted:

Health History


Early Life:

Was this animal bred or adopted?
Bred
Adopted
Unsure
Any known issues during pregnancy or birth?
Yes
No

Trauma and Health Events:

Has your animal experienced any of the following (check all that apply):

Current Health and Lifestyle

Are they currently diagnosed with any illnesses or disorders?
Yes
No

Diet and Hydration

Are they fed on a schedule?
Yes
No

Behavior and Environment

Are there any behavioural concerns?
Yes
No
Have they been exposed to:

Vaccination and Medical History

Are vaccinations current?
Yes
No
Has your animal had any recent veterinary care or treatments?
Yes
No

Exercise and Activity Levels

Are there any limitations to their activity or mobility?
Yes
No

Behavioral History

Have there been any recent changes in behavior or mood?
Yes
No
Does your animal display any repetitive behaviors (e.g., pacing, licking)?
Yes
No

Social Interactions

Are there any notable social or behavioral challenges?
Yes
No

Shelter and Environmental Details

Have they had any changes to their environment recently (e.g., moves, new household members)?
Yes
No

Previous Training or Rehabilitation

Has your animal undergone any training or behavioral therapy?
Yes
No

Goals and Expectations

Consent for Data Collection

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Date
Day
Month
Year
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