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  • Medical History Form - DVMNeedles

  • Welcome to my world of Integrative Medicine, the melding of Conventional Modern Medicine and Traditional Chinese Medicine. You are about to fill out a medical history that far surpasses your past experiences at veterinary clinics. Some of these questions will be straight forward, and some will be “weird”, to say the least. They are only weird from the modern perspective. In Traditional Chinese Medicine, clues to the body’s health are everywhere, we just have to ask the correct questions.

    Please fill out this very long questionnaire to the best of your ability. Past clients have found it best to read the questionnaire, fill out the more mundane points, and observe the pet for a couple of days to answer the more “obscure” questions.

  • PLEASE FILL OUT EACH SECTION COMPLETELY

    The more information you provide to me, the more I can do for your pet.

  • Owner Information


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  • Medical History Form


  • Environment and Living Situation



  • Mental Status and Vocalization

  • I realize that for those of you who work between 8 AM and 6 PM, it is difficult to answer some of the questions with specific times. Rely on your observations during your days off and on weekends. Unless there is a lot going on in the household, most pets will stick to their same schedules of behavior, even if it is a weekend. We all know about the dog/cat who wants to eat at 6:00 AM, even if it is a Saturday or Sunday.

  • Urination and Defecation

  • Please take the time to observe your pet’s behavior regarding urination and defecation for the next few days, then answer these questions.

  • Appetite and Drinking Behavior

  • Dry Food #1

  • Dry Food #2

  • Dry Food #3

  • Wet Food #1

  • Wet Food #2

  • Wet Food #3

  • Treat #1

  • Treat #2

  • Treat #3

  • Meat #1

  • Meat #2

  • Meat #3

  • Veggie #1

  • Veggie #2

  • Veggie #3

  • Fruit #1

  • Fruit #2

  • Fruit #3

  • Personality Traits

  • In Traditional Chinese Medicine (TCM), every individual, personality wise, falls into one or two particular elements.


    The state of our health can be influenced by our “inherent” elemental status. While every individual possesses all five of the elemental personalities, one or two of the elements are usually dominant.

  • Past Health Issues

  • From the TCM perspective, past illnesses, (especially if they are similar), give clues to the source of the body’s imbalance. It can also give us clues to the Elemental status of the individual. Looking back over your pet’s life, please check ALL that apply.

  • Record of Health Issues   

    Regarding your patient’s health problems. From the holistic point of view, past health problems are related to current health problems. This makes it important to always look at the past as well as the current problems.

    Previously, you checked off health issues that your pet had during his/her life.

    Please list in chronological order the major health issues that your pet has had over his/her lifetime.

    Major health issues include any medical issue that prompted you to seek veterinary help and/or any health issue that, although not life threatening, continues to remain or return.

  • Primary Complaint(s) for the Consultation

    If there is more than one health concern, please list them in decreasing importance from your perspective.

  • PAIN CONSULTATION QUESTIONS

  • List all medication/supplements that were given in chronological order. Indicate if improvement was seen with the medications/supplements.

  • Other Medical Conditions

  • CURRENT MEDICATIONS, DIETARY SUPPLEMENTS, NUTRICEUTICALS, HERBS

  • Should be Empty: