The Animal Doctors TCVM Questionnaire

The Animal Doctors TCVM Questionnaire
Client's Name*

First NameLast Name
Email Address
example@example.com
Pet's Name*
Which doctor do you have a TCVM appointment with?*

Dr. Stephanie Young (Acupuncture / Tui Na (Massage)Dr. Kyle Stevenson (Acupuncture)
What is the date of your scheduled appointment?

MonthDayYear
Date
In order to provide your pet with the most appropriate, helpful, and timely treatment plan, we need to ask some additional questions that we may or may not already have in your pet's current medical record. Knowing this information ahead of time will help us to formulate a treatment plan in a more efficient manner. Thank you for your time and thoroughness!
Please list all of the food items that you are currently giving to your pet, including snacks. For your pet's main food source, please indicate the brand and flavor you are feeding, as well as how much and how often.*
Please list all of the medications, including supplements and over the counter medications, that you are currently giving to your pet. Please include the dosage and frequency of each medication/supplement.*
What is your pet's current appetite?*

ExcellentGood/Fair - noticeably different compared to how it has always beenI have to dress it up/disguise it a lot the time to get them to eat itPoor - noticeably not eating much of anything at all
What is your pet's current stool quality?*

NormalOkay - it can be picked up but is relatively softDiarrhea - it cannot be easily picked upWatery Diarrhea - there is no way that it can be picked upI'm Not Sure
What are your pet's urinary habits like?*

NormalMore FrequentLess FrequentAccidents (in the house/outside the litterbox)I'm Not Sure
What are your pet's drinking habits like?*

NormalIncreasedDecreasedI'm Not Sure
What activities do your pet engage in on a regular basis? (example: daily 1-mile walks)*
Does your pet seek cool areas to lay (example: hardwood floor) or warm areas to lay (example: under blankets, on a heat vent, in the middle of the sunshine)?*

Cool AreasWarm AreasIt VariesI'm Not Sure
Please describe your pet's personality around other animals of the same species (example dog-dog or cat-cat).*

They like to be in charge.They can be stand-offish or aggressive.They are high-energy and want to play with everyone.They are good-natured and go with the flow.They have a mothering instinct.They are indifferent or would prefer to hang out with people.They are terrified of other animals +/- hide from them.
Please describe your pet's personality around people.*

They like to be in charge and may sometimes act aggressively.They are high-energy, don't sit still, and want to play with everyone.They are good-natured and go with the flow.They are indifferent or would prefer to hang out with other animals.They are terrified of other people +/- hide from them.
Does your pet usually require anti-anxiety medications (example: trazodone, gabapentin) for his/her regular veterinary appointments?*

YesNo
What are you hoping that acupuncture treatment will help your pet with?*
Are you interested in herbal supplements that may also help your pet?*

YesNoI'm Not Sure / Maybe
Is there any other information that you would like to share with us that may be helpful for us to know about your pet?
Should be Empty: