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Canine Patient TCVM History

First Name

Last Name

Pet Name

Pet Species

Pet Breed

Pet Sex

Pet Birthdate

Weight

Is your dog on Heartworm preventative?

Is your dog on Heartworm preventative?
A
B

Please list your major concerns/complaints regarding your dog’s health in order of their importance. Describe your concerns in detail and be sure to include the approximate date when each problem began.

What medical problems or surgeries has your dog experienced in the past?

If your dog is on any medications or supplements please list them:

Please answer the following as they apply to your dog.

Prefers

Prefers
A
B

Personality

Personality
A
B

Appetite

Appetite
A
B

Thirst

Thirst
A
B
C

Feces

Feces
A
B
C

Diet: What is your dog’s diet?

Which choice best describes your dogs: choose one in each category

Interactions with people

Interactions with people
A
B
C
D
E

Greeting Strangers

Greeting Strangers
A
B
C
D
E

Patience

Patience
A
B

Excitability

Excitability
A
B
C
D

In General

In General
A
B
C
D
E

When sleeping does your dog (if yes please explain in the box below)

When sleeping does your dog (if yes please explain in the box below)
A
B

Explain

Does your dog sleep

Does your dog sleep
A
B

Does your dog have stiffness?

Does your dog have stiffness?
A
B

What is your dog’s response to massage?

What is your dog’s response to massage?
A
B

From the list, mark all that apply to this patient:

From the list, mark all that apply to this patient: