• Medical History Form - DVMNeedles

  • Welcome to my world of Integrative Medicine, the melding of Conventional Modern Medicine and Traditional Chinese Medicine. You are about to fill out a medical history that far surpasses your past experiences at veterinary clinics. Some of these questions will be straight forward, and some will be “weird”, to say the least. They are only weird from the modern perspective. In Traditional Chinese Medicine, clues to the body’s health are everywhere, we just have to ask the correct questions.

    Please fill out this very long questionnaire to the best of your ability. Past clients have found it best to read the questionnaire, fill out the more mundane points, and observe the pet for a couple of days to answer the more “obscure” questions.

  • PLEASE FILL OUT EACH SECTION COMPLETELY

    The more information you provide to me, the more I can do for your pet.

  • Owner Information


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  • What is the best way to contact you?
  • How did you learn about our clinic? Check ALL that apply

  • Medical History Form

  • Species

  • Environment and Living Situation

  • Dog:

  • Cats:

  • Select all that applies to your pet:

  • Mental Status and Vocalization

  • Recently and overall, my pet’s attitude toward life, family, and surroundings have been:
  • Compared to six months to a year ago, my pet’s attitude is:

  • I realize that for those of you who work between 8 AM and 6 PM, it is difficult to answer some of the questions with specific times. Rely on your observations during your days off and on weekends. Unless there is a lot going on in the household, most pets will stick to their same schedules of behavior, even if it is a weekend. We all know about the dog/cat who wants to eat at 6:00 AM, even if it is a Saturday or Sunday.

  • Check all that apply:
  • Facial Expression
  • Rest and Activity Level
  • Posture, Gait. and Movement:

  • Urination and Defecation

  • Please take the time to observe your pet’s behavior regarding urination and defecation for the next few days, then answer these questions.

  • Check ALL that apply in regard to urination
  • Check ALL that apply in regard to defecation
  • Regarding the frequency of soft stools or diarrhea:
  • How Often?
  • What time of day?
  • Check ALL that apply
  • Vomiting
  • How Often?
  • What time of day?
  • Check ALL that apply
  • Contents of vomit?
  • Respiration (Check ALL that apply)

  • Appetite and Drinking Behavior

  • Check ALL that apply
  • Diet

  • Dry Food #1

  • How Often?

  • Dry Food #2

  • How Often?

  • Dry Food #3

  • How Often?

  • Wet Food #1

  • How Often?

  • Wet Food #2

  • How Often?

  • Wet Food #3

  • How Often?

  • Treat #1

  • How Often?

  • Treat #2

  • How Often?

  • Treat #3

  • How Often?

  • Meat #1

  • How Often?

  • Meat #2

  • How Often?

  • Meat #3

  • How Often?

  • Veggie #1

  • How Often?

  • Veggie #2

  • How Often?

  • Veggie #3

  • How Often?

  • Fruit #1

  • How Often?

  • Fruit #2

  • How Often?

  • Fruit #3

  • How Often?

  • Personality Traits

  • In Traditional Chinese Medicine (TCM), every individual, personality wise, falls into one or two particular elements.


    The state of our health can be influenced by our “inherent” elemental status. While every individual possesses all five of the elemental personalities, one or two of the elements are usually dominant.

  • Check ALL that apply
  • Which of the following jobs or careers can see your pet doing?

  • Past Health Issues

  • From the TCM perspective, past illnesses, (especially if they are similar), give clues to the source of the body’s imbalance. It can also give us clues to the Elemental status of the individual. Looking back over your pet’s life, please check ALL that apply.

  • Record of Health Issues   

    Regarding your patient’s health problems. From the holistic point of view, past health problems are related to current health problems. This makes it important to always look at the past as well as the current problems.

    Previously, you checked off health issues that your pet had during his/her life.

    Please list in chronological order the major health issues that your pet has had over his/her lifetime.

    Major health issues include any medical issue that prompted you to seek veterinary help and/or any health issue that, although not life threatening, continues to remain or return.

  • Is the condition resolved or ongoing?
  • Is the condition resolved or ongoing?
  • Is the condition resolved or ongoing?
  • Is the condition resolved or ongoing?
  • Is the condition resolved or ongoing?

  • Primary Complaint(s) for the Consultation

    If there is more than one health concern, please list them in decreasing importance from your perspective.

  • PAIN CONSULTATION QUESTIONS

  • What was the level of pain when it FIRST observed? Level of Pain: 0 is no pain at all and 5 is the worst pain possible.
  • Did the pain spread to other parts of the body?
  • What is the current pain level?
  • Does the pain come and go or is it all the time?
  • Is the pain worse with rest?
  • Is the pain worse with exercise?
  • Is the pain better in the morning?
  • Is the pain better in the evening?
  • Does the level of pain appear different on different days?
  • Does the level of pain change with damp weather?
  • Does the level of pain change with cold weather?
  • Does the level of pain change with hot weather?
  • Does your pet like you to massage the area of pain?
  • Does your pet dislike you touching the area of pain?
  • Does your pet yelp suddenly for no reason?
  • Any swelling in the area of pain?
  • Any heat or cold in the area of pain?

  • List all medication/supplements that were given in chronological order. Indicate if improvement was seen with the medications/supplements.

  • Effect of medication/supplement on the level of pain
  • Effect of medication/supplement on the level of pain
  • Effect of medication/supplement on the level of pain
  • Effect of medication/supplement on the level of pain
  • Effect of medication/supplement on the level of pain
  • Effect of medication/supplement on the level of pain

  • Other Medical Conditions

  • CURRENT MEDICATIONS, DIETARY SUPPLEMENTS, NUTRICEUTICALS, HERBS

  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Frequency
  • Should be Empty: