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?

Better in the morningBetter in the eveningCan't tell
What is your pet's temperature preference?

Shade/tileSunny/carpetNo Preference
Rate your pet's thirst:

NormalIncreasedDecreasedFrequentSmall sips
Rate your pet's appetite:

NormalIncreasedRavenousDecreasedFinicky
Describe any vomiting, check all that apply:

NoneFoodFluidsNoisySilentFrequentSporadic
When does your pet vomit?
How long after eating does your pet experience vomiting?
Describe your pet's stool, check all that apply:

NormalDiarrheaConstipationMucusBloodyIncontinenceGassySmelly
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:

NormalIncreasedDecreasedIncontinenceRetention
Describe your pet's urine, check all that apply:

PaleYellowDarkBloodySmellyPainful
Describe your pet's behavior, check all that apply:

RelaxedHappyHyperactiveOutgoingConfidentQuietTimidAngryFearfulSadWorriedCaringLoyalFriendlyAggressive
Does your pet's pain get worse with...

NoneRestExerciseHeatColdDampMorningEvening
Does your pet's pain get better in the morning?

YesNo
How long has your pet been experiencing pain?
Describe your pet's sleep, check all that apply:

NormalIncreasedDecreasedRestlessVocalizesDreams
Where does your pet sleep?
Describe your pet's cough, check all that apply:

NoneDryWetLoudSoftProductive (foam)Productive (phlegm)
When is your pet coughing the most?

DaytimeNighttimeBoth, worse at night
What type of food does your pet receive? Check all that apply.

Dry KibbleCannedHomemadeRawCooked
What is your pet's respiration?

NormalHeavyStrongWeakShallowOut of Breath (walks)
What type of exercise does your pet get?

NormalLotsToo littleIntolerant (refuses/quits)
Does your pet like massages?

YesNo
List any allergies your pet has to food:
Does this cause itching?

YesNo
If yes, where?
General Medical Issues
Check all that apply

Separation anxietyHeart problemsInsomniaThunderstorm phobiaRestlessnessTachycardiaFeverExcessive pantingAsthmaSinusitisCoughingBreathing problemsNose problemsDry skinSneezingNasal dischargeWeak voice
Does your dog have problems with the following? Check all that apply

LiverLigamentsEyesEarsNailsFootpadsTeethAnal glandsAggressionSeizuresUrinary issuesBack painBone or growth issuesWeakness in rear endFearfulDeafReproductive problemsArthritis
Does your pet experience any of the following? Check all that apply.

Loss of appetiteConstipationDiarrheaVomitingOverweightGum diseaseWeak musclesAnxiety
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
Should be Empty:

PATIENT INFORMATION AND HISTORY FOR TCVM AND VETERINARY ACUPUNCTURE

Basic Information

Patient History

General Medical Issues