skip to Main Content

Initial Patient Questionnaire

Thank you for your interest in Traditional Chinese Veterinary Medicine for your pet! I am pleased to offer this service to pets in the low country. Below is some information to complete and submit prior to your pet’s appointment.

Please note: Your pet’s medical records and this form must be submitted 48 Hours Prior to scheduled consultation and treatment. Please send medical records to [email protected].

"*" indicates required fields

Address*
Animal Species*
When was your pet's most recent rabies vaccination?*
Has your pet ever show aggression toward: (select all that apply)*
Has your pet been seen by a veterinarian for this issue?*
Has your pet received acupuncture before?*
Are you interested in Chinese herbal medication for your pet?*

Clinical Signs Survey

Please answer the following questions about your pet to the best of your ability.
My Pet is sleeping:*
My pet's activity level is:*
Does your pet dream while sleeping?*
What is your pet's temperature preference?*
How is your pet's appetite?*
How is your pet's water intake?*
What is your pet's stool quality?*
Choose the option that describes your pet's urination:*
Is your pet vomiting?*
Is your pet coughing?*
Choose the option that best describes your pet's stiffness/arthritis pain:*

Pet Personality/ Constitution

The 5 Element Theory is a fundamental part of TCVM and organizes natural processes into the following components: Fire, Earth, Metal, Water, and Wood. Check all the boxes that apply to your pet's personality and health:

Fire Constitution

Normals
Abnormals

Earth Constitution

Normals
Abnormals

Metal

Normals
Abnormals

Water

Normals
Abnormals

Wood

Normals
Abnormals