Middlesex Veterinary Center - TCVM Patient Intake Questionnaire

TCVM Patient Intake Questionnaire

Thank you for choosing our Traditional Chinese Veterinary Medicine practice. To provide the best care for your animal companion, please complete this questionnaire prior to your appointment. This information helps us understand your pet's constitution, personality, and health patterns according to TCVM principles.
Pet and Owner Information
Today's Date*

MonthDayYear
Date
Owner's Name*

First NameLast Name
Pet's Name*
Species*
Breed*
Color*
Age*
Weight*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Primary Concerns
1. What are your main health concerns for your pet?*
2. When did you first notice these issues?*
3. Have these concerns:*

ImprovedWorsenedRemained the same
4. Rate the severity of the main concern (1 = mild, 10 = severe):*
5. What makes the condition better?*
6. What makes the condition worse?*
Previous Treatments
1. What treatments have you tried for the current condition?*
2. Current medications/supplements and dosages:*
3. Has your pet had any surgeries? If yes, please list with dates:*
Diet & Digestion
1. What is your pet's current diet? (Please list brands, types, and amounts)*
2. How many meals per day? Treats? (Type and frequency)*
3. Does your pet prefer*

Warm foodRoom temperatureCold food from refrigerator
4. Is your pet's appetite*

StrongModeratePoorVariable
5. Does your pet*

Gulp FoodEat slowlyLeave food for laterGuard food
6. Describe your pet's thirst*

Drinks large amountsDrinks normal amountsRarely drinksGulps water
7. Stool consistency*

Firm and formedSoftLoose/diarrheaHard/dryVariable
8. Stool frequency (how many times does your pet poop per day?)*
9. Any digestive issues (check all that apply)?*

VomitingRegurgitationGasBloatingBad breathOther
Sleep & Energy
1. How many hours does your pet sleep in 24 hours?*
2. Where does your pet prefer to sleep?*

Cool surfacesWarm placesNo preference
3. Sleep position*

Curled up tightlyStretched outOn backChanges frequently
4. Energy level*

Very highHighModerateLowVariable throughout day
When is your pet most active?*

MorningAfternoonEveningNight
Does your pet tire easily during exercise?*

YesNo
Behavior & Personality
1. Which best describes your pet's personality? (Check all that apply)*

Outgoing/socialTimid/shyIndependentClingyAnxiousAggressivePlayfulCalmStubbornSensitive
2. How does your pet react to new people?*

FriendlyCautiousFearfulAgressiveIndifferent
3. How does your pet react to other animals?*

FriendlyCautiousFearfulType option 4AgressiveIndifferent
4. Does your pet have any behavior issues? Check all that apply:*

Separation AnxietyExcessive barking/vocalizationDestructive behaviorAggressionFearfulnessHouse soilingOther
5. Does your pet seek out*

Physical contact/pettingBeing near you but not touchedBeing alone
Environment & Preferences
1. Where does your pet spend most time?*

IndoorsOutdoorsBoth
2. Does your pet prefer:*

Warm environmentsCool environmentsNo strong preferance
3. Does your pet seek out:*

SunShadeWarm spots (heaters, vents)Dislikes rainNo weather sensitivity
4. How does your pet react to different weather?*

Dislikes heatDislikes colesDislikes rainNo weather sensitivity
5. Does your pet like to be groomed?*

YesNo
Five Element Indicators
1. Sound of voice/vocalization:*

Loud howl/barkSharp/piercingGroaning soundsWeak/quietWhining
2. Which emotion does your pet display most prominently?*

Fear/timidityAnger/irritabilityJoy/excitmentGrief/sadnessWorry/anxiety
3. Season when symptoms worsen:*

SpringSummerFallWinter
4. Does your pet have any of these eye conditions?*

RednessExcessive tearingDrynessDischargeNone
Females Only (If NOT spayed)
Are you filling out this form for an unaltered (not spayed) female?*

YesNo
1. Age at first heat:*
Frequency of heat cycles:*
2. Any changes in behavior during heat? If yes, describe:*
3. Has she had puppies/kittens? If yes, how many liters?*
4. Any complications with pregnancy or birth? If yes, describe:*
Previous Medical History
1. Vaccinations (dates of most recent):*
2. Parasite prevention used:*
3. Please check any conditions your pet has experienced:*

AllergiesArthritisCancerDental problemsEar infectionsHeart issuesKidney/bladder issuesLiver problemsRespiratory issuesSeizuresSkin problemsThyroid conditionOther
4. Has your pet ever had a reaction to medication? If yes, please describe: *
Additional Information
Is there anything else you would like us to know about your pet? Thank
Thank you for completing this questionnaire. This information will help us develop the most appropriate TCVM treatment plan for your pet. Please bring this completed form to your appointment or email it to us beforehand.

Middlesex Veterinary Center

537 Great Rd.

Littleton, MA 01460

(978)952-8500

info@middlesexvetcenter.com
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TCVM Patient Intake Questionnaire

Pet and Owner Information

Primary Concerns

Previous Treatments

Diet & Digestion

Sleep & Energy

Behavior & Personality

Environment & Preferences

Five Element Indicators

Females Only (If NOT spayed)

Previous Medical History

Additional Information