Traditional Chinese Veterinary Medicine
Nutrition and Supplements
Patient History Form
Client Acceptance Form
Veterinary Referral Form
This form is to be filled out by the person responsible for the care of the pet coming to Holistic Veterinary Care.
Patient History Form
Indicates required field
Female - Spayed
Male - Neutered
Color and Markings
Age or Date of Birth
Because diet is so important to the health of an animal, please list all foods and treats that your pet has eaten in the last 2 months. Include all commercially prepared and any home cooked or people food that your pet may receive. Also, list any treats, bones, etc. that your pet may consume.
List all medications and supplements that your pet has taken in the past 2 months. Include those prescribed by your veterinarian, and those that you purchased on your own. This should include any injections adminstered by your veterinarian, not including vaccinations. Be as specific as possible.
In the following area, please list all vaccines that your pet has received in the past year. Be as specific as possible and include dates administered.
Describe your pets daily activity level. For example: How many hours are spent engaged in active play? Do they enjoy a daily walk, and for how long? Do they tire after a few minutes or a few hours after being active?
In the following area, describe your pet's traits. For example: Is your pet shy or outgoing? Friendly to other pets/people? Any fears or anxieties? Is he/she bonded to a particular family member, or just loves everyone? Include anything that comes to mind.
My Pet Prefers
Warmth (Likes to lay in the sun/under blankets)
Cold (Likes to lay on cool floors/gets hot easily)
Great (Will eat anything)
Poor (Picky/skips meals)
Very poor(Must entice to eat regularly)
Any recent vomiting or diarrhea?
Any abnormal drinking/urinary habits?
Below, please describe the reason for your appointment request. List the primary concern that you have first, then any other concerns you may have no matter how minor you think they are. Any change, even small, may be important.
Reason(s) for Appointment Request
Is there anything else we should know?
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