..:: Healing Paws Veterinary Care ::..

Western Medicine History

If your pet was treated previously for this problem, please answer the following questions:

Traditional Chinese Medicine (TCM) History

Energy and Well-being:

Mobility

Mobility level:
1. Normal
2. Reduced
3. Increased
Mobility is best:
1. Morning
2. Afternoon
3. Night
4. Consistent
My pet has a specific area that is weak or lame:
1. Yes
2. No
If yes, please circle all that apply:
1. Right Front Leg
2. Left Front Leg
3. Right Back Leg
4. Left Back Leg

Pain

My pet is in pain:
1. Yes
2. No
If yes, for how long?
If you answered "yes", please complete the following regarding your pet's pain:
Pain is __/10 (with 10 being the worst)
Is the pain in a specific area?
1. Yes
2. No
If yes, where?
After rest it is:
1. Better
2. Worse
After exercise it is
1. Better
2. Worse
How does temperature and weather affect your pet's pain?
Is your pet's pain better:
1. Morning
2. Afternoon
3. Evening
4. No Time Difference

Nutrition/Digestion/Urinary

Appetite:
1. Normal
2. Reduced
3. Increased
Your pet:
1. Loves to eat
2. Not food motivated
3. Picky
Vomiting:
1. None
2. Occasional
3. A couple of times per week
4. Often
If vomiting is a regular occurrence, please describe when it happens and what it looks like:
Stools:
1. Normal
2. Increased
3. Decreased
Is there blood or mucous in the stool?
1. Yes
2. No
Does your pet have gas?
1. Yes
2. No
Water intake:
1. Frequent small sips
2. Large amounts at one time
3. Moderate
Urine:
1. Normal
2. Increased
3. Decreased
4. Incontinent
5. Straining
6. Vocalizes
Urine color:
1. Normal
2. Clear
3. Dark Yellow
Odor of urine:
1. Normal
2. No odor
3. Strong odor

Skin

My pet has:
1. Brittle nails
2. Dry pads
3. Dry skin with large flakes
4. Dry skin with small flakes
Is your pet itchy?
1. Yes
2. No
If yes, please circle all that apply:
1. Sometimes
2. Daytime
3. At night
4. All the time
Has your pet's hair coat changed?
1. Yes
2. No
If yes, please describe:

Reproduction

Breathing

1. Normal
2. Coughs
Has had a change in breathing, describe:
My pet's voice or noises that he/she makes are: the same/have
changed, describe:
Is there anything else we should know about your pet's health or
emotional history?

Integrative Examination Form