Combined PPA, CS, and TCVM This form authorizes Traditional Chinese Veterinary Medicine diagnostics and therapies, and delivery of your approved care for your pet. Please fill this form out completely and accurately. URLThis field is for validation purposes and should be left unchanged.* Indicates required informationPet’s Name(Required)Primary Contact Name(Required) First Last Primary Symptoms, Questions, or Concerns(Required)Primary Phone Number(Required)Secondary Contact Name First Last Secondary Phone NumberTCVM treats the patient using herbal medicine, acupuncture, and food therapy by targeting what is out of balance and can often involve treating the “branches” until the “roots” of the problem are exposed. I understand that Integrative medicine is a holistic approach to treating the whole patient and may include a combination of conventional and unconventional therapy to attain the best patient outcome.(Required)Select oneYesNoPet parents can help by making daily observations of their pet and reporting any subtle changes. I understand positive changes and improvements take time because the goal is healing instead of symptomatic treatment, and that herbal therapies and diet alterations are often recommended and will change based on how the patient is responding.(Required)Select oneYesNoI understand initial acupuncture is typically recommended at weekly intervals for 4 weeks based on response, and follow-up appointments for herbal therapies range from every 2-3 weeks to every few months depending on the pet.(Required)Select oneYesNoI understand that acupuncture and herbal medicine are considered to be alternative therapies in veterinary medicine. I have been made aware by my veterinarian that my pet may have a condition that is treatable by utilizing conventional medications.(Required)Select oneYesNoThis field is hidden when viewing the formREQUIRES REVIEW REQUIRES REVIEW No Pet Personality AssessmentThis section can help us better understand your pet's medical history. In Chinese medicine, all medical problems are related. This information helps us tailor our treatment to your pet's specific needs. Check all that apply:FireNormals Lively Communicative Very Friendly Affectionate Loves to be Petted Center of the Party Abnormals Insomnia Separation Anxiety Restless Excess Heat Rapid Heart Rate Heart Problems WoodNormals Decisive Assertive Confident Strong Impulsive Athletic-Stamina Alpha Animal Abnormals Ligament Problems Liver Problems Red Eyes Angers Easily Ear Problems Nail Problems Footpad Problems Anal Sac Problems EarthNormals Relaxed, Laid Back Sociable Round and Large Loyal Serene and Balanced Cares for Others (Motherly) Abnormals Diarrhea Constipation Loss of Appetite Vomits Gum Disease Weak Muscles Overeats, Obese Worries WaterNormals Careful Curious Self-Contained Likes to Hide Meditative Slow and Consistent Abnormals Rear Weakness Fearful Bone and Back Issues Urinary Problems Disturbed Growth Deafness Reproductive Problems Worries MetalNormals Loves Order Obeys the Rules Aloof Symmetrical Body Disciplined Attitude Good Haircoat Abnormals Asthma Dry Skin Sinus Problems Breathing Disorder Nose Problems Cough Clinical Signs AssessmentThis section gives us a better understanding or your pet's personality which can also reveal imbalances that may need to be addressed. Please select all that apply and fill in the blanks where necessary.Energy/Spirit Strong Weak Happy Sad Eyes Normal Discharge Red Weepy Dry Eye Appetite Increased Decreased No Change Oral Normal Bad Breath Poor Oral Health Gastrointestinal Normal Regurgitation Vomit Chronic Acute Type of Vomit Bile Fluid Undigested Food Foreign Material Stool Normal Soft Dry Diarrhea Blood Little Odor Malodorous Chronic Diarrhea Constipation Skin Normal Red Dry Flaky Itchy Greasy Crusty Oozing Odor Hair Loss Seasonal Year Round Is your pet on flea prevention?(Required)YesNoDoes your pet take antibiotics? Chronic Rare Never Does your pet have ear infections?(Required)YesNoThirst Increased Decreased No change Urination Small Amount Large Amount Strong Odor Clear Leaking Straining Crystals Stones Normal Voice Loud Quiet Cough None Dry Wet At Night Daily Neurologic Focal Seizures Grand Mal Seizures Tremors None Does your pet have neurologic symptoms? If so, please explain.Does your pet take medications for neurologic symptoms? If so, please explain.Temperature Preference Shade/Cool Sun/Warm Neutral Sleep Habits No Change More Less Paces at Night Hard Surface Soft Bed Mobility Limping Pain None Where is the mobility problem?Has your pet had any Xrays, MRIs, or surgery?(Required)YesNoMobility Continued Intermittent Mild Chronic Severe Worse in AM Worse in PM Worse with Cold Worse with Heat Worse Before Walk Worse After Walk Enjoys Massage Dislikes Massage Exercise Yes No Once Daily Twice Daily Strenuous Behavior Fearful Anxiety Separation Anxiety Obsessive Compulsive Angers Easily Likes People Dislikes People Likes Dogs Dislikes Dogs Likes Cats Dislikes Cats Please explain anything further below, or list any medical problems not addressed fully aboveBy signing below, I authorize the use of alternative therapies for my pet.Date(Required)SignaturePlease only click "Submit" once and do not leave this page! This may take a few seconds.
