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Integrative Examination Form
Sex
Male
Female
Altered ?
Yes
No
What is your pet's main reason for seeking/needing holistic treatments?
Western Medicine History
If your pet was treated previously for this problem, please answer the following questions:
Since your pet's last veterinary visit, is he/she:
Yes
No
Please list to your best ability:
Traditional Chinese Medicine (TCM) History
Energy and Well-being:
Energy level in general:
Normal
Reduced
Increased
Energy is highest:
Morning
Afternoon
Night
Consistent
Attitude/Mood is best:
Morning
Afternoon
Night
Consistent
My pet is:
Outgoing
Shy
Aggressive
My pet is:
Happy
Content
Restless
Crabby
Depressed
My pet prefers:
To be cool
To be warm
No preference
Sleep:
Normal
Decreased
Increased
Restless at night
Dreams:
None
Vocalization
Running
Mobility
Mobility level:
Normal
Reduced
Increased
Mobility is best:
Morning
Afternoon
Night
Consistent
My pet has a specific area that is weak or lame:
Yes
No
If yes, please circle all that apply:
Right Front Leg
Left Front Leg
Right Back Leg
Left Back Leg
Pain
My pet is in pain:
Yes
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?
Yes
No
If yes, where?
After rest it is:
Better
Worse
After exercise it is
Better
Worse
How does temperature and weather affect your pet's pain?
Is your pet's pain better:
Morning
Afternoon
Evening
No Time Difference
Nutrition/Digestion/Urinary
Appetite:
Normal
Reduced
Increased
Your pet:
Loves to eat
Not food motivated
Picky
Vomiting:
None
Occasional
A couple of times per week
Often
If vomiting is a regular occurrence, please describe when it happens and what it looks like:
Stools:
Normal
Increased
Decreased
Is there blood or mucous in the stool?
Yes
No
Does your pet have gas?
Yes
No
Water intake:
Frequent small sips
Large amounts at one time
Moderate
Urine:
Normal
Increased
Decreased
Incontinent
Straining
Vocalizes
Urine color:
Normal
Clear
Dark Yellow
Odor of urine:
Normal
No odor
Strong odor
Skin
My pet has:
Brittle nails
Dry pads
Dry skin with large flakes
Dry skin with small flakes
Is your pet itchy?
Yes
No
If yes, please circle all that apply:
Sometimes
Daytime
At night
All the time
Has your pet's hair coat changed?
Yes
No
If yes, please describe:
Reproduction
Fertile
Infertile
Not Applicable
Describe any reproduction problems your pet has had:
Breathing
Normal
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?
Send