Patient History Form
Traditional Chinese Veterinary Medicine
Pet's Name
*
Owner's Name
*
First Name
Last Name
Clinic Location
*
Kenton Animal Hospital
Cathedral Animal Hospital
Major complaint
*
Health Condition
Preference
*
Yang/Heat: Shade, cool surfaces (concrete/tile)
Yin/Cold: Sun, warm surfaces (carpet)
Other
Personality
*
Yang/Heat: Hyperactive, outgoing, confident, strong (fire/wood)
Yin/Cold: Quiet, timid, less confident (earth, water)
Other
Diet
*
Yang/Heat: Dry, hot food (chicken, mutton, venison)
Yin/Cold: Iced or cold (fish, tofu)
Other
Thirst
*
Yang/Heat: Thirsty, high thirst
Yin/Cold: Low thirst
Other
Appetite
*
Yang/Heat: Good, ravenous
Yin/Cold: Good, finicky
Other
Feces
*
Yang/Heat: Dry, bloody, malodorous
Yin/Cold: Loose, diarrhea
Other
Urine
*
Yang/Heat: Short stream, malodorous, bloody
Yin/Cold: Long stream, urine leakage
Other
Medication
*
Yang/Heat: Steroids, Yang or Qi tonics
Yin/Cold: Antibiotic, heat-clearing, Yin tonics
Other
Age
*
Yang/Heat: Young
Yin/Cold: Old
Other
Disease course
*
Yang/Heat: Short
Yin/Cold: Long
Other
Vaccinations
*
Yang/Heat: Acute disease following vaccines
Yin/Cold: Chronic disease following frequent vaccinations
Other
Please look at your previous answers to answer the following questions:
*
Heat Condition: 4 or more Yang signs (Excess Heat) // 2 or less Yin signs (Yin Deficiency)
Cold Condition: 2 or less Yang signs (Yang/Qi Deficiency) // 4 or more Yin signs (Excess Cold)
Combination: 3 or more signs of each
Other
Personality
Interactions
*
Aggressive / Bossy (Wood/Yang)
Very friendly (Fire/Yang)
Okay with all (Earth/Yin)
Okay / Aloof / Confident (Metal/Yin/Yang)
Timid / Not confident / Runs away (Water/Yin)
Other
Greets Strangers
*
Barks / Attacks (Wood/Yang)
Wags tail warmly (Fire/Yang)
Slow reaction (Earth/Yin)
Does not care (Metal/Yin/Yang)
Runs away (Water/Yin)
Other
Patience
*
No (Wood/Yang) (Fire/Yang)
Yes (Earth/Yin) (Metal/Yin/Yang) (Water/Yin)
Other
Excitability
*
Yes (Wood/Yang)
Easily (Fire/Yang)
Slow (Earth/Yin)
No (Metal/Yin/Yang) (Water/Yin)
Other
Reaction to Acupuncture
*
No problems (Earth/Yin)
Cooperative (Wood/Yang) (Metal/Yin/Yang)
Sensitive (Water/Yin)
Highly sensitive (Fire/Yang)
Other
Other
*
Insecure / Fear (Water/Yin)
Irritable (Wood/Yang)
Vocal (Fire/Yang)
Mellow (Earth/Yin)
Follows rules (Metal/Yin/Yang)
Other
Submit
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