Holistic Pet Care New Patient Form Date:* Pets Name:* First Client Name:* First Last Holistic Chinese Diagnostic History FormWelcome to our Holistic Clinic! Please take several minutes to fill out this form. This detailed history helps our holistic doctors establish a Holistic medical diagnosis, aiding in our treatment and herbal recommendations. We encourage you to fill this form out anytime you feel there are major changes in your pets history. You may ask for this form at any of your recheck examinations.Please List your Primary Concerns today:*Please Check off All that Apply:1. Appetite* Normal Ravenous Poor Eater and/or Not Food Motivated2. Thirst* Normal Loves Water Not a big drinker Unsure3. Feces* Normal Consistently Dry Consistently Soft Mucus Malodorous Bright Red Blood Dark Black Yellow / Orange Incontinent4. Urine* Normal Amount Urinates Frequently Does not Urinate Frequently Leaking / Dribbling Large Amounts Small Amounts5. Urine Smell* Strong Little Smell None Unsure6. Urine Color* Clear Slightly Cloudy Cloudy Turbid Unsure7. Voice* Very Vocal Soft Voice Loud Voice Doesn't Vocalize / Hardly Ever8. Behavior* Friendly Anxious around Fearful of Aggressive around Hyperactive / Overly Exuberant Sluggish Calm / ReservedAnxious around:*Fearful of:*Aggressive around:*9. Sleep* Great Sleeper Restless / Agitated Insomnia / Can't Sleep Snores Dreams Unsure OtherOther:*10. Hair Coat* Soft / Shiny Dry / Dull Dander Excessive Shedding Balding Texture or Color Changing OtherOther:*11. Skin* Normal Large Dandruff Flakes Small Dandruff Flakes Greasy / Oily Brittle Thinning Itchy Color Changing Rash Bad Odor OtherOther:*12. Temperature Preference* Loves Sun / Heat Loves Cool / Shade / Laying on Cool Floors Either / Neutral OtherOther:*13. Surface Preference* Hard Surfaces / Floors Soft Surfaces / Bedding Neutral OtherOther:*14. Stiffness, if present, is WORSE after Rest Exercise Both Unsure Cold Weather Warm Weather Unsure OtherOther:*15. Stiffness, if present, is BETTER after Rest Exercise Both Unsure Cold Weather Warm Weather Unsure OtherOther:*Please check any Chronic Problems your pet has / is suffering from:Eyes Dry Eye Excessive Tearing Red Eyes Corneal Ulcers Glaucoma Other:Other:*Ears Chronic Ear Infections Ear Hematomas Itchy Ears Other:Other:*Tongue Dry Excessively Wet / Abnormal Drooling Red Purple White Other:Other:*Mouth Dry Excessively Wet / Abnormal Drooling Red Purple White Other:Other:*Nose Dry / Cracked Nose or Skin Above Nose Sneezing / Reverse Sneezing Chronic Discharge that is:*ClearBloodyOrange / YellowWhiteDigestive Vomiting Intermittently Vomiting Daily Vomits Bile Vomits Grass Vomits Whole Food Vomits BloodIn general, do you feel your pet smells? If so, how would you describe it? Rancid Scorched Fragrant Rotten Putrid Other:Other:*Five Element QuizThe 5 elements are an old philosophy used to describe interactions and relationships between personality, health, and predispositions to common ailments. Once a holistic veterinarian has reviewed your pet and this quiz, they will supply you with the information of your pet's element.Balanced Lively Communicative Very Friendly Affectionate Loves to be Petted Center of the PartyUnbalanced Insomnia Separation Anxiety Restless Excess Heat Rapid Heart Rate Heart ProblemsBalanced Relaxes & Laid Back Sociable Round & Large Loyal Serene & Balanced Cares for Others (Motherly)Unbalanced Diarrhea Constipation Loss of Appetite Vomits Gum Disease Weak Muscles Over Eats WorriesBalanced Decisive Assertive Confident Strong Willed Impulsive Athletic-Stamina AlphaUnbalanced Ligament Problems Liver Problems Red Eyes Angers Easily Ear Problems Nail/Foot Pad Issue Anal Gland IssueBalanced Careful Curious Self Contained Likes to Hide Meditative Slow & ConsistentUnbalanced Rear Weakness Fearful Bone/Back Issues Urinary Problems Disturbed Growth Reproductive IssuesBalanced Loves Order Obeys the Rules Aloof Symmetrical Body Disciplined Attitude Good HaircoatUnbalanced Asthma Dry Skin Sinus Issues Breathing Disorder Nose Problems Cough
