TCVM Questionnaire Owner Information:Name(Required) First Last Address(Required) Street Address Primary Phone:(Required)Email:(Required) Pet Information:Name(Required) First Last Species(Required) Species Breed(Required) Breed Sex Male Female Birthdate/Age MM slash DD slash YYYY What is your pet’s overall personality? Dominant, leader Social, energetic, excitable Laid back, easy going Independent, aloof Shy, quiet, nervous Does your pet have any fears or phobias? Describe. First Does your pet have any trouble falling asleep? Staying asleep? Describe. First Does your pet have active dreams? Yes No Where does your pet sleep? First Does your pet have a preference for cool or warm places? Prefers cool places Prefers warm places Other What is your pet’s diet? Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? What treats and other food does your pet eat? How many and how often? Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? What type of exercise does your pet get? (Activity/Frequency) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Describe your pet's appetite (normal, increased, decreased, etc) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Describe your pet's thirst (normal, increased, decreased, etc) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Describe your pet's stool (frequency, appearance, volume, odor) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Describe your pet's urination (frequency, appearance, volume, odor) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Does your pet experience vomiting or gas? (frequency, description) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Does your pet cough? (frequency, description) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? Does your pet pant excessively? (all the time? specific times of day?) Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source? What medications is your pet currently taking? (list all name, dose strength, frequency, even if only once in awhile or as needed) Does your pet have chronic or intermittent pain? Where? Why? Does anything make it better or worse? (Paragraph Text) What supplements is your pet currently taking? (list all name, dose strength, frequency, even if only once in awhile or as needed) What are your pet’s current signs or symptoms? (list all name, dose strength, frequency, even if only once in awhile or as needed) Does your pet have any past history or medical conditions or surgery? (list all name, dose strength, frequency, even if only once in awhile or as needed) Does your pet have any aggression toward people or other animals? (list all name, dose strength, frequency, even if only once in awhile or as needed) What are your expectations for treatment of your pet with acupuncture and integrative medicine? (list all name, dose strength, frequency, even if only once in awhile or as needed) Is there any other information that you feel it is important for us to know to treat your pet? (list all name, dose strength, frequency, even if only once in awhile or as needed) Is there any other information that you feel it is important for us to know to treat your pet? The Five Elements Please check any below that apply to your pet at any point in their life. (Don’t worry about the category titles right now. At your appointment, these will be explained in more detail.) Fire Lively communicative Very friendly Affectionate Loves to be petted Center of the party Insomnia Separation anxiety/restless Excess heat/rapid heart rate Heart problems Wood Decisive Assertive Confident Strong Impulsive athletic-stamina Alpha animal Ligament problems Liver problems Red eyes Angers easily Ear problems Nail problems Footpad problems Anal sac issues Earth Relaxed, laid back Sociable Round and large Loyal Serene and balanced Cares for others (motherly) Diarrhea Constipation Loss of appetite Vomits Gum disease Weak muscles Overeats-obese Worries Water Careful Curious Self-contained Likes to hide Meditative Slow and consistent Rear weakness Fearful Bone and back issues Urinary problems Disturbed growth Deafness Reproductive problems Metal Loves order Obeys the rules Aloof Symmetrical body Disciplined attitude Good haircoat Asthma Dry skin Sinus problems Breathing disorder Nose problems Cough Δ
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