Range Animal Hospital LLC

E6116 US 2
Ironwood, MI 49938

(906)932-3531

www.rangeanimalhospital.com

 

TCVM Client Consultations


 

TCVM Client Consultations Form

Patient Name: (required)

Owner's Name: (required)
First Name (required)
Last Name (required)
Species: (required)

Breed: (required)

Date of Birth: :
Age: (required)

Sex: (required)

Male
Male Neutered
Female
Female Spayed


What is your patient’s main reason for seeking/needing acupuncture? (Specific Health Problems, General Wellness, etc) (required)

If your pet was treated previously for this problem, please answer the following questions:
What diagnostics have been done and what were the results? (ex. Bloodwork, X-rays):

What treatments were utilized?

Did the pet show any improvement? If so, please describe:

Since your pet’s last veterinary visit, is he/she:

The same
Better
Worse


Please list to your best ability:
Current Medications: (required)

Current herbs and/or supplements: (required)

Current diet: (required)

Current exercise regimen: (required)

Traditional Chinese Medicine (TCM) history: (in each section, please check all that apply)
Energy and Well-Being
Energy level in general: (required)

Normal
Reduced
Increased


Energy is highest: (required)

Morning
Afternoon
Night
Consistent


Attitude/mood is best: (required)

Morning
Afternoon
Night
Consistent


My pet is: (required)

Outgoing
Shy
Aggressive


My pet is: (required)

Happy
Content
Restless
Crabby
Depressed


My pet prefers: (required)

To be cool
To be warm
Does not have a preference


Sleep: (required)

Normal
Decreased
Increased
Restless at night


Dreams: (required)

None
Vocalization
Running


Mobility
Mobility level: (required)

Normal
Reduced
Increased


Mobility is best: (required)

Morning
Afternoon
Evening
Night
Consistent


My pet has a specific area that is weak or lame: (required)

Yes
No


If “Yes,” please check all that apply:
Front right leg
Front left leg
Back right leg
Back left leg
Pain
My pet is in pain: (required)

Yes
No


If “Yes,” how long:

If “Yes,” please complete the following regarding your pet’s pain
Pain is _____/10 with 10 being the worst

1
2
3
4
5
6
7
8
9
10


Is the pain in a specific area? Please explain if so:

After rest is it:

Better
Worse


After exercise is it:

Better
Worse


How does weather/temperature affect your pet’s pain?

Better in:

Morning
Afternoon
Evening
Night
No time difference


Nutrition/Digestion/ Urinary
Appetite: (required)

Normal
Increased
Decreased


My pet: (required)

Loves to eat
Is not food motivated
Is picky


Vomiting: (required)

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: (required)

Normal
Soft
Diarrhea
Hard and dry
Constipation
Incontinent


There is:

Blood
Mucous in the stool


Odor of stool: (required)

Normal
Strong
No odor


Does your pet have gas? (required)

Yes
No


Thirst: (required)

Normal
Increased
Decreased


Water intake: (required)

Frequent small sips
Large amounts at one time
Moderate


Urine: (required)

Normal
Increased
Decreased
Incontinent
Straining
Vocalizes


Color of urine? (required)

Normal
Clear
Dark yellow


Odor of urine? (required)

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? (required)

Yes
No


If “Yes” please check all that apply:
Sometimes
During day
At night
All the time
Has your pet’s hair coat changed? (required)

No
Yes


Reproduction
(required)

Fertile
Infertile
Not applicable


Describe any reproduction problems your pet has had:

Respiration/breathing:
(required)

Normal
Coughs
Has had a change in breathing


If your pet has had a change in breathing, please describe:

My pet’s voice or noises that he/she makes are: (required)

The same
Have changed


If your pet's voice or noises have changed, please describe:

Is there anything else we should know about your pet’s health or emotional history?


Verify the reCAPTCHA: