Nutritional Pet Profile (NPP)™ Questionnaire

Please fill out this entire questionnaire completely. Also please send appropriate test results from your veterinarian. Upon completion of all the information, please call to confirm receipt.

If you do not feel comfortable sending personal information over the internet, please download the Nutritional Pet Profile (NPP)™ Questionnaire. in .pdf format, fill out the form completely and fax to us. If you have questions please contact us.

Visualize Your Animals Wellness
Personal Information
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
E-Mail
Home Phone
Office Phone
Cell Phone
Fax
Animal's Information
Animal's Name
Species Canine Feline Horse Bird
  Other (please specify)
Breed
Date of Birth
Sex Male Female
Weight
Spayed/Neutered Yes    Date No
Veterinarian's Name
Veterinarian Hospital
Veterinarian Phone
Veterinarian Fax
Please Indicate Which Service You Are Contacting Us For (Check One)
NPP™ Consult with Dr. Bob $350   
NPP™ Without Consult $250
Questions About Your Animal
1. What is the specific condition, disease or diagnosis or your animal? (Please attach medical history recorded by your veterinarian)
Check Each Condition That Applies To Your Animal
Anemia
Explain/Type
Arthritis/Dysplasia/Tendontious
Explain/Type
Autoimmune Disease
Explain/Type
Behavior Emotions
Explain/Type
Brain/Nerve
Explain/Type
Cancer
Explain/Type and Location
Ear or Eye
Explain/Type
Gland Disease (Adrenal, Female, Male, Pituitary, Pancreas, Thyroid, etc..)

Explain/Type

Heart
Explain/Type
Infectious Disease (Bacterial, Tick-borne, Viral etc..)
Explain/Type
Kidney
Explain/Type
Liver/Gall Bladder
Explain/Type
Mouth/Gum/Teeth
Explain/Type
Sinus/Bronchial/Lung
Explain/Type
Skin
Explain/Type
Stomach/Intestinal
Explain/Type
Urinary/Bladder
Explain/Type
2. What specific tests were done to obtain this condition/diagnosis? (Please send your veterinarian’s reports)
3. What is your animal’s current diet? (Include any table scraps, home cooked foods and treats)
4. What supplements (if any) is your animal receiving?
(Vitamins, Minerals, Homeopathic, Enzymes, Antioxidants, Phytonutrients, Nutraceuticals etc...)
5. Is your animal currently taking any medications? If so, name the specific drug(s), dosage and frequency?

6. Is your animal currently receiving any type of therapy? (Acupuncture, Medical. Surgical. Chemotherapy, Radiation, Cortisone, etc... how often and the dose)
7. What is your animal’s vaccination history? Be specific and include dates when possible.(Please fax or email vaccine history after filling out this form or have your veterinarian supply this information by fax or email).
8. In your opinion, what is your animal’s emotional status and history?
9. Has your animal ever been in a shelter or been rescued? (Please specify dates)
10. Is your animal grieving? (Please explain)
11. What is your current flea and tick prevention program and how often do you administer?
12. What are your health goals for your animal?

13. What are your main concerns about your animal?
14. Any additional comments?
15. How did you hear about us? (Please give person's name if a friend)
16. How would you like to receive the NPP™ Wellness Program?
Mail eMail Fax Pick-up at Earth Animal
WARNING: Speak with your Veterinarian before vaccinating your animal. If your animal suffers from a compromised immune system or is in a fragile state of health, consider the possible side effects. Vaccinate with intelligence. We suggest titer testing.
*A $25.00 fee will be charged to you if 24-hour notice is not given for cancellation of a Phone Consultation.
Refund Policy on Services and Products: All Custom Blended Homeopathic's (CBH) are non-refundable. Nutraceutical Support Formulas and Liquid Remedies must be unopened with seal still intact and must be returned within 15 days from the ship date for a full refund.

*NOTE - All supplements and food sold separately.

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this will delete all your information.

Thank you.