Alternative Medicine Patient History

Welcome to Westway Animal Clinic. Our approach with Traditional Chinese Veterinary Medicine involves understanding, as best as we can, what you and your pet have already been through. It is important to us to take a thorough history so that we can customize an approach for you. Rather than spend time during your appointment going through these details, we feel it is important that you can answer our questions from the comfort of your own home, at your own pace. Please complete the form to the best of your ability, we’ll take it from there…

Alternative Medicine Patient History

Owner Name *

Pet's Name *

Owner contact details *

Daytime Phone Number

Owner contact details

Evening Phone Number

Owner contact details *

Email

Pet's age *

Male or female? *

Neutered/Spayed? *

Species/Breed *

Presenting complaint *

When did the symptoms start? *

Did symptoms change over time? *

Yes

No

If symptoms have changed, please provide details

Appetite

Normal

Increased

Decreased

No Appetite

Drinking

Normal

Increased

Decreased

Defecation

Normal

Dry/Constipated

Soft/Diarrhea

Urination

Normal

Increased

Decreased

Leaking Urine/Incontinent

Sneezing

Yes

No

Coughing

Yes

No

Does your pet have difficulty falling asleep?

Yes

No

Does your pet have trouble staying asleep?

Yes

No

Is your pet dreaming during sleep?

Yes

No

How is your pet's energy or stamina?

Normal

Increased

Decreased

Where does your pet prefer to sleep?

Warm Places

Cold/Cooler Places

When not sleeping, which does your pet prefer?

Warm Places

Cold/Cooler Places

Does your pet travel to different cities/countries?

Yes (Provide Details Below)

No

Please provide details of travel history

Has your pet been previously diagnosed with any medical conditions by a veterinarian?

Yes (Provide Details Below)

No

Please provide details of any previous medical conditions

Has your pet received any previous treatments/medications?

Yes (Provide Details Below)

No

Please provide details of any previous treatments/medications (to the best of your ability)

What are the main health problems that your pet is currently experiencing? Please select all that apply. *

Nasal congestion, nasal discharge, sneezing, trouble breathing or coughing

Vomiting, lack of appetite, diarrhea, constipation or gas

Seizures, irritability, anger/aggression, liver, gallbladder, eye, foot, tendon, or ligament issues

Behaviour problems, startled by loud noises or sudden movements, limb jerking, crying during sleep or cardiovascular disease

Rear weakness, urinary leakage, change in urine color, infertility, disc disease, bone, kidney or bladder issues

Increased water intake/thirsty, panting or cool seeking behavior

Decreased activity level, exercise intolerance or general weakness

Dandruff, lack of stamina, cracked paw pads

Warm-seeking behaviours, shivering or cold body (temperature or to the touch)

Other/None-of-the-Above

How long has the current problem been present?

Acute/Short Course of Disease

Chronic/Long Course of Disease

What conditions cause the problem to worsen?

Worse with hot temperature (summer, day time)

Worse with cold temperature (winter, night time)

Worse in the morning

Worse in the late afternoon

Worse over night

Worse after exercise

Worse after rest

Has your pet demonstrated any behavior changes recently? Please select all that apply.

Aggression, irritability, impatience

Restlessness, anxiety

Abnormal behaviour at night

Inactivity

Warm-seeking

Cool-seeking

What medications and therapies are administered to your pet currently? Please select all that apply.

Yearly Vaccinations

Steroids

Antibiotics

Anti-inflammatories

Long course of a cold herbal medication

Long course of a Yang tonic

Long course of a Blood tonic

What kinds of foods make up your pet's diet?

Primarily raw food

Primarily dry kibble

Primarily wet food

Primarily cooked human food

What type of food does your pet prefer?

Prefers eating wet foods

Prefers eating dry foods

How does your pet perform during exercise?

They push themselves and exert a lot of energy

They don't love exercise and will do the minimum

If your pet is limping: Limping is better after exercise

If your pet is limping: Limping is worse after exercise

Please provide details of the type of exercise your pet typically gets in a week

How would you describe your pet's personality? Choose the Element that most closely applies. *

Wood - Dominant, aggressive, competitive, confident, fearless like a pioneer.

Fire - Easily excited, friendly, playful, sensitive, difficult to calm down, noisy and talkative, tends to be the center of attention.

Earth - Laid back, easy going, sweet, slow moving, tolerant like a peacekeeper.

Metal - Aloof, independent, likes order and rules, quiet, confident and consistent.

Water - Timid, shy, fearful, willing to/wants to be alone, hides or runs away.