Chinese Medicine Patient Form Name* First Last Email* Enter Email Confirm Email Best phone number to reach youPet's Name* Pet's age and breed* Diet*Please describe current diet, including snacks and treats.SymptomsWe are glad you have expressed interest in Chinese medication. Please take your time filling these questions out. These details are important and will help us provide the best possible care for your pet.DAMP HEAT Any bad odor including flatulence or halitosis? Any itching? Does itching seem worse from bathing/swimming? Straining to urinate or defecate? Heat Intolerance? Hyper excitable? Any aggression? Warm paws? Do they have an appetite with decreased thirst? Do they have an appetite with increased thirst? Have you noticed any red lesions? Any yellow discharges from any orifices? BLOOD and YIN DEFICIENCY Nervous or timid? Reluctance to play with larger animals? Barks vigorously at strangers? Noise sensitivity? Bullies other smaller or more submissive animals? Territorial behavior? Example: stealing other pets' food/toys Small fine dandruff? Cool paws and ears? Dry eyes? Constipation? Chronic weight loss? (but good appetite) Restlessness and pacing DAMPNESS/PHLEGM Tendency to chronic weight gain Tendency to form cutaneous masses such as lipomas Has greasy hair or clumping of hair Has larger flaky dander versus fine dander Waxy ears Mucous discharge Vomiting of saliva or phlegm Increased urination GASTROINTESTINAL SYMPTOMS Nausea Vomiting Diarrhea Constipation Gas and bloating Straining MUSCULOSKELETAL SYMPTOMS Stiffness/lameness/soreness Dislike of being touched Movement becomes better with heat Movement becomes worse with heat Movement becomes better with cold Movement becomes worse with cold URINARY SYMPTOMS History of urinary tract infection Incontinence PM/nighttime urination RESPIRATORY SYMPTOMS Cough Sneezing Snoring Shortness of breath Reverse sneezing Poor stamina SKIN Itching (please put in notes what season it began) Ear infections Failure of hair to regrow? Hair loss? Large dander flakes Fine powder-like dander Greasy hair coat HEAD Lesions on nose Noise sensitivity Dulled senses BEHAVIOR Changeable temperament Fear aggression Timid GENERAL Temperature preference cool Temperature preference warm Increased appetite Increased thirst Energy in the morning Sleepy in the morning Vigorous dreaming Nocturnal restlessness NOTESPlease include any clarifications or notes related to questions above.CAPTCHANameThis field is for validation purposes and should be left unchanged.
