Owner Name:________________________________		Animal/Pet Name:____________________________
Address:____________________________________		Pet Age:____________
City/ST/Zip:_________________________________		Specie:______________
Phone:_____________________________________		Breed:______________________________
		Sex: M____ F____

List specific behavioral problems or situations: (separate piece paper)
When did they start:
Has anything provoked the problem:
Life style changes:
Changes in household: (moves, death in family, etc.)
Be as detailed as you feel necessary:
What was animals behavior like before problem:
(if you know the start)

1. How did your animal friend come into your life?

_____ A. Bought at a pet store		_____ E. Answered ad in paper
_____ B. Gift from a friend		_____ F. From a breeder
_____ C. Adopted from an animal shelter		_____ G. Picked up at grocery store
_____ D. Found abandoned

If you marked 1C - How did the animal come into the shelter?
Was there a history of abuse? YES / NO
If yes, please explain:

If you marked 1D - Where and how was the animal found?

If you marked 1E - What was the reason for the animal to leave its current home?

2. How old was your animal friend when you started your life together?

3. Have you ever used Flower Essences on your animal friend before? YES / NO
If yes, what type:
For what purpose:
Did you notice an improvement?

4. Has your animal friend been spayed of neutered? YES / NO
If yes, date if known:

5. List any health conditions or concerns, include surgery dates if possible:

6. List the type and name of the food your animal friend is currently eating

Brand Name _____________________________ Canned/Dry/Pellet/Seed
How often do you feed your friend? ___________ x per day.
Prescribed  by your Vet?   YES / NO

7. Do you give your animal friend vitamins or supplements? YES / NO
If yes, what type?
For what condition?

8. Please check all that apply:
__ Shock, trauma, illness, injury, surgery, emergencies
__ Breaking undue emotional attachments to the caretaker, such as whining and moping dogs waiting for the owner to return
__ Unknown fear or terror in animal
__ Extreme tension or stress, such as a scared or frightened animal that is trapped
__ Jealous pets, especially when jealousy involves another per vying for the attention of the caretaker
__ Before and after a major move; helps to break links to old places of residence
__ For nervous conditions in animals
__ Excessive barking
__ Encourages interspecies communication
__ Confusion or being overwhelmed when traveling or when there is a change in schedule
__ Animals giving birth
__ Animal that bite
__ Helping the body to use its own healing forces
__ Lifting the spirits of an animal that is depressed due to illness or old age
__ To help animals living together in a group or herd to adjust, especially when
a new animal has been introduced or when a “group” animal become a single pet
__ Shy
__ Emotional upset, gas or vomiting
__ Is your animal in training? YES NO
__ Taken from mother to young?

9. Does your animal friend live: INDOORS OUTDOORS BOTH

10. How many hours in your animal friend left during the day? ___________

11. Does your animal live with other animals? YES NO

If yes, please list what types and their names:
		1.  ___________________________
		2.  ___________________________
		3.  ___________________________