ENERGY HEALING CLIENT FORM

HANDLERS / OWNERS NAMEADDRESSPHONEEMAILDATE

ANIMAL’S NAME AGESPECIESBREEDLENGHTS OF TIME IN YOUR LIFENUMBER OF PREVIOUS OWNERS, IF KNOWNRESCUEVETERINARIANPRIMARY REASON FOR THERAPY (areas of complaint, pain, or dysfunction, behavior etc.)

1. HAS YOUR ANIMAL EVER BEEN INJURED, EXPERIENCED SURGERY OR OTHER TYPES OF TRAUMA? This includes falls, vehicle accidents, medical surgeries or treatments, abuse, cranial injury, broken limbs etc.

YES NO

If yes, please describe?

2. DOES YOUR ANIMAL HAVE ANY KNOWN ILLNESSES OR DISEASES? YES NOIf yes, please describe?

Pet Wellness Worx | 72 Plattekloof Rd PLattekloof Glen 7460 | 0215585098reception@petwellnessworx.co.za |086 520 8660

3. ARE YOU EXPERIENCING TRAINING, PERFORMANCE OR BEHAVIOR PROBLEMS? YES NOIf yes, please describe?

4. DOES YOUR ANIMAL HAVE CANCER? YES NOIf yes, please describe?

5. DOES YOUR ANIMAL HAVE ARTHRITIS OR ANY JOINT DISORDERS? YES NOIf yes, please describe?

6. IS YOUR ANIMAL PRESENTLY TAKING ANY DRUGS OR MEDICATION? YES NOIf yes, please describe?

7. DOES YOUR ANIMAL HAVE ANY OTHER MEDICAL CONDITIONS NOT DISCUSSED YET?

YES NO

If yes, please describe?

8. WHAT DOES YOUR ANIMAL LIKE OR DISLIKE ? (or has sensitivities/fear towards, f.e. smells, sounds etc)

If relevant, please describe?

Pet Wellness Worx | 72 Plattekloof Rd PLattekloof Glen 7460 | 0215585098reception@petwellnessworx.co.za |086 520 8660