Systems Insight Form CAN

Form
Pets name
Age
Weight
Sex
Breed
Owner
Date
Please select a number for each symptom only if it applies to your dog. LEAVE BLANK if it does not apply.

1= Mild or not often 2= Moderate or somewhat frequent 3= Severe or constant

Group One - SYMPATHETIC

Rows	Score
Dry Mouth, eyes, nose
Keyed up, fails to calm
Nervous
Unable to relax, startles easily
Vomits or regurgitates with excitement
Tends towards aggression
Fear biter
High anxiety
Isolates away from family or pets
Afraid of storms, fireworks, loud noises
Doesn't adapt easily to routine change
Obsessive compulsive behaviour

Group Two - PARASYMPATHETIC

Rows	Score
Joint stiffness with rising
Always seems hungry
Couch potato-like attitude
Slow starter, slow mover
Subject to infections
Eyes and nose watery
Eats dirt
Constipation, diarrhoea, alternating
Poor circulation, sensitive to cold
Moist body, often an odour
Sleeps more then used to
Little interest in anything

Group Three - CARBOHYDRATE METABOLISM, SUGAR HANDLING

Rows	Score
Trembles, episodes of weakness
Seizures
Disoriented at times
Increased sleep, decreased activity
Wheat, corn, rice, barley, oats in diet
Urinating large amounts
Hungry often, eats fast
Change in appearance of eyes
Cannot loss weight even with diet
Eats faeces
Weight loss
Behaviour changes
Increased water consumption
Overweight
Passes gas

Group Four - CARDIO RESPIRATORY, CIRCULATION

Rows	Score
Exercise intolerance
Significant loss of muscle mass
Fainting, collapse
History of heartworms
Cough, especially at rest
Seems disoriented at times
Rear legs tremble, weak
Enlarged heart and/or heart murmur
Swelling in rear legs
Difficulty breathing
Shortness of breath
Has had pneumonia more than once

Group Five - HEPATIC, GALL BLADDER

Rows	Score
On meds over a long time
Stool watery or diarrhoea
Appears bloated
Restless, can't get comfortable
Increased shedding
General itchiness
Sporadic vomit/diarrhoea
Allergies
Seizures, tremors
Change in appetite
Frequent anaesthetics
Food sensitivities
Anal sac problems, scooting
Licks or chews at feet or anus
Stands with back arched
Elevated cholesterol, triglycerides
Elevated liver enzymes, lipase
Gas, indigestion
Ocular discharge, red eyes
Early morning vomit
Crusty lip sores

Group Six - DIGESTION

Rows	Score
Vomits after fatty meal
Halitosis
Pale-coloured stool
Stomach distress common
History of pancreatitis
Recurrent diarrhoea
Rancid odour to stool
Belches, regurgitation
Intermittent vomiting
Excessive or chronic eye drainage
Poor coat
Recent intestinal parasites

Group Seven - A - THYROID GLANDS

Rows	Score
Increased shedding
Thinning, spare coat, bald spots
Warts
Dry, scaly skin
Obese or can't lose weight
Oily, greasy coat, body odour
Weak pulse
Elevated blood cholesterol
Fatty tumors
Stiff gait, exercise intolerance
Depression, mentally dull
Seeks cool places to rest
Back/neck problems
Increased pigment to skin
Weak knee ligaments

Group Seven - B - PITUITARY GLAND

Rows	Score
Failing memory
Abnormal thirst
Weight gain around rear end, fat pads
Neutered male retains sexual activity
Abnormal heat cycles of intact females
Pigment spots to skin

Group Seven - C - ADRENAL GLANDS, HYPERACTIVE

Rows	Score
Excessive water consumption
Increased urination
Thin skin
Decline in arthritic symptoms
Panting more then used to
Lethargic
Pacing
Weak knees, weak muscles
Increased appetite
Distended abdomen
Change in behaviour
Thinning fur

Group Seven - D - ADRENAL GLANDS, HYPOACTIVE

Group Eight - MUSCULOSKELETAL

Rows	Score
Older dog
History of any joint surgery's
Back or disc Problems
Bone spurs or enlarged Joints
Difficulty getting up and down
Arthritic, degenerative joint disease
Has had ligaments damaged
Rapidly accumulates tartar on teeth
Losing muscle tone in legs and back
Healing facture in body
Suffering from a sprain or strain
Difficulty supporting weight

Group Nine - RENAL, URINARY

Rows	Score
Abnormal or frequent urination
History of bladder infections
Reduced renal function
Hight blood calcium&/or phosphorus
History of bladder stones
Licking at penis or vulva
Cries when urinating
Elevated vitamin D
Leaking urine
Wants to go outside more often
Prostate enlarged
14 or more years old

Group Ten - IMMUNE

Rows	Score
Increased shedding
Red bumps to skin
Scabs, sores or crusts to skin
Dandruff, flaking
Has had cancer
Eye infections
Treated for parasites
Body or ear odour
Ear infections
Experienced a vaccine reaction
Frequent infections
Odour that returns shortly after bath
Moist or heat under front or rear legs
Enlarged lymph nodes
Dental infection

Group Eleven - PAIN

Rows	Score
Lameness, abnormal gait
Withdrawn, hiding
Reluctant to move
Dislike or tolerance of handling
Overall activity less then normal
Looks depressed
Hanging or tucked tail
Decreased appetite
Recent surgery, dental Infection
Playing less
Less interested in going for a walk
Change in mood, grumpy
Hunched back or swaying back
Groaning, moaning, grunting
Weeping red, cloudy or squinting eyes
Heavy panting, increased heart rate
Change in appetite & any type of food willing to eat
Licking inanimate objects
Wobbly
Shifting weight off area of the body
Licking excessively an area of body
Restlessness, pacing
Lower or tilted head or ears
Temperamental, yelp or growl at others
Change in toilet habits

TO THE OWNER: Please list below the five main physical or and health complaints for this dog in order of importance
Diet
Other comments you would like to make ?
Should be Empty: