Patient Information and History Form for TCVM and Veterinary Acupuncture

PATIENT INFORMATION AND HISTORY FOR TCVM AND VETERINARY ACUPUNCTURE
Basic Information
DATE

MonthDayYear
Date
CLIENT NAME
PET NAME
BREED
AGE
GENDER
DIET
LIST ANY MEDICATIONS
LIST ANY SUPPLEMENTS/HERBS
Patient History
When did symptoms start?
How long have they been going on?
When do symptoms occur? (i.e. winter, fall, spring, summer)
Is there a time of day symptoms occur?
Describe any other time symptoms occur:
What is your pet's energy level?
What is your pet's temperature preference?
Rate your pet's thirst:
Rate your pet's appetite:
Describe any vomiting, check all that apply:
When does your pet vomit?
How long after eating does your pet experience vomiting?
Describe your pet's stool, check all that apply:
Describe the color of your pet's stool:
How frequently does your pet have a bowel movement?
Describe your pet's urine frequency, check all that apply:
Describe your pet's urine, check all that apply:
Describe your pet's behavior, check all that apply:
Does your pet's pain get worse with...
Does your pet's pain get better in the morning?
How long has your pet been experiencing pain?
Describe your pet's sleep, check all that apply:
Where does your pet sleep?
Describe your pet's cough, check all that apply:
When is your pet coughing the most?
What type of food does your pet receive? Check all that apply.
What is your pet's respiration?
What type of exercise does your pet get?
Does your pet like massages?
List any allergies your pet has to food:
Does this cause itching?
If yes, where?
General Medical Issues
Check all that apply
Does your dog have problems with the following? Check all that apply
Does your pet experience any of the following? Check all that apply.
Other Pertinent Symptoms, Signs or Tendencies
Please use this space to describe, in as much detail as you like, the concerns you have with your pet's health.
Zakiya Mudiwa, DVM, CVA Indian Trail Animal Hospital 160 Corporate Blvd Indian Trail, NC 28079 704-821-7040
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PATIENT INFORMATION AND HISTORY FOR TCVM AND VETERINARY ACUPUNCTURE

Basic Information

Patient History

General Medical Issues