Thank you for choosing Herbsmith Custom Formulations for your pet. A one-time formula consultation fee of $45 is charged for determining the best formula for your dog or cat (whether a custom-designed formula or Classic Formula).  This fee is in addition to the regular container prices.  When you submit this form, you will be automatically taken to the Herbsmith store to process the $45 fee.
 

Questionnaire:
 
Owner's Name:
Address:
City:
State:
Zip:
Day Phone Number:
Evening Phone Number:
E-Mail:
Dog's Name:
Male
Neutered          Spayed		 Female
Not Fixed
If pregnant, how many months?
Age:
Breed:
What is the dog's main use?
(Ex: showing, agility, breeding, pet, etc.)

What is the primary complaint?

What is the dog's current and past medical history?

Behavior/Temperment:
How is the behavior?
How is he/she with other dogs?
Is the dog calm or hyperactive? Does he/she stand quiet or move around frequently? Other?

Has the "normal" temperament changed recently? How?

Digestive System:
Is there a history of vomiting, diarrhea, gurgley abdomen, etc.?

Feeding:
How quickly does he/she eat?
What are the current feeding amounts of dry food?
Moist food?
Treats, snacks, chew bones,ect?
Other?
Have these amounts recently changed? Yes No
If so, how?
 
Water Consumption:
Approximate amount of water consumed daily? 
(Example: excessive, minimal, etc.)
Has this amount recently changed? Yes  No
If yes, how?
Quality of stool:
Ex: dry, watery, color, odor, etc.
Urinary System:
Quality (dark in color, foul smelling, etc.)
What is the "normal" volume or urination?
Has this amount recently changed? Yes No
If  yes, how?
Any accidents or leakage?
Respiratory System:
History of coughing:when,where?
How long does the cough last?
Does anything make it worse?
What makes it better?
Environment:
What type of environment does the dog live in? (Ex: Kennel,house, etc.)
If in an outdoor kennel, what type of footing does he/she have?
(Ex: cement,dirt, etc.)
What type of bedding is used?
(Ex: straw, sawdust, etc.)
Lameness History:
Is the dog lame? YesNo
If so, where?
When is the dog lame?
How long has he/she been lame?
Could the lameness be due to any type of trauma? A fall, over worked, hard play, etc.
How often is the dog lame?
What makes the lameness worse?
What makes the lameness better?
Movement:
How does the dog move over all? (Fast, slow, etc.)
Has the movement in different gaits or transitions recently changed? YesNo
If so, how? 
Does the dog have difficulty going up or down steps?
Getting in and out of vehicles?
Other?
Does your dog wear a collar, harness, etc?

Coat and Skin:
How is the hair coat quality?
Any problems with shedding out seasonal coats?
Any skin rashes, itchiness, etc? Please include all areas effected and the length of time it has beeen a problem.
Do any of the above conditions seem better or worse at different times of the year? Summer-heat, winter-cold?
Is there any history of ear infections?  Yes No
Have you ever noticed poor color of the gums or tongue?  Yes No
Any history of tendon problems?  Yes No
Any history of heart problems?  Yes No
Any history of eye problems?  Yes No

Any other information we should know?

When you click Send, you will be automatically redirected to the Herbsmith store to process the $45 formula consultation fee.