Page 1 of 1
Canine Patient TCVM History
First Name
*
Last Name
*
Owner Phone
*
Pet Name
*
Pet Species
*
Pet Breed
*
Pet Sex
*
Pet Birthdate
Weight
*
Is your dog on Heartworm preventative?
*
Is your dog on Heartworm preventative?
A
Yes
Is your dog on Heartworm preventative?
B
No
Which one?
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
Shady or cool locations (concrete/tile)
B
Sun or warm locations (carpet)
Personality
*
Personality
A
Hyperactive/outgoing/confident/strong
B
Quiet/Timid/Less Confident
Appetite
*
Appetite
A
Ravenous or Good
B
Good or finicky
Thirst
*
Thirst
A
Thirsty
B
Less Thirsty
C
Normal
Feces
*
Feces
A
Dry, Bloody or malodorous
B
Loose or diarrhea
C
Normal
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
Aggressive or bossy
B
Very Friendly
C
Okay with Everyone
D
OK, Aloof (confident)
E
Timid (hides)
Greeting Strangers
*
Greeting Strangers
A
Barks
B
Wags tail warmly
C
slow reaction
D
does not care
E
runs away
Patience
*
Patience
A
No
B
Yes
Excitability
*
Excitability
A
No
B
Slow
C
Easily
D
Yes
In General
*
In General
A
Irritable
B
Vocal
C
Mellow, Laid back
D
Follows the Rules
E
Insecure
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
vocalize or wake you up at night
B
experience muscle jerking while asleep
Explain
*
Does your dog sleep
*
Does your dog sleep
A
too much
B
too little
Does your dog have stiffness?
*
Does your dog have stiffness?
A
Yes
If yes, then is it worse
If yes, then is it worse
in the morning
in the evening
with cold
with heat
with damp
after a walk
before a walk
Does your dog have stiffness?
B
No
What is your dog’s response to massage?
*
What is your dog’s response to massage?
A
Likes
B
Dislikes
From the list, mark all that apply to this patient:
*
From the list, mark all that apply to this patient:
lively
From the list, mark all that apply to this patient:
communicative
From the list, mark all that apply to this patient:
very friendly
From the list, mark all that apply to this patient:
affectionate
From the list, mark all that apply to this patient:
loves to be petted
From the list, mark all that apply to this patient:
center of the party
From the list, mark all that apply to this patient:
insomnia
From the list, mark all that apply to this patient:
separation anxiety
From the list, mark all that apply to this patient:
restless
From the list, mark all that apply to this patient:
excess heat
From the list, mark all that apply to this patient:
rapid heart rate
From the list, mark all that apply to this patient:
heart problems
From the list, mark all that apply to this patient:
decisive
From the list, mark all that apply to this patient:
assertive
From the list, mark all that apply to this patient:
confident
From the list, mark all that apply to this patient:
strong
From the list, mark all that apply to this patient:
impulsive
From the list, mark all that apply to this patient:
athletic-stamina
From the list, mark all that apply to this patient:
alpha animal
From the list, mark all that apply to this patient:
ligament problems
From the list, mark all that apply to this patient:
liver problems
From the list, mark all that apply to this patient:
red eyes
From the list, mark all that apply to this patient:
angers easily
From the list, mark all that apply to this patient:
ear problems
From the list, mark all that apply to this patient:
nail problems
From the list, mark all that apply to this patient:
footpad problems
From the list, mark all that apply to this patient:
anal sac issues
From the list, mark all that apply to this patient:
careful
From the list, mark all that apply to this patient:
curious
From the list, mark all that apply to this patient:
self contained
From the list, mark all that apply to this patient:
likes to hide
From the list, mark all that apply to this patient:
meditative
From the list, mark all that apply to this patient:
slow and consistent
From the list, mark all that apply to this patient:
rear weakness
From the list, mark all that apply to this patient:
fearful
From the list, mark all that apply to this patient:
bone and back issues
From the list, mark all that apply to this patient:
urinary problems
From the list, mark all that apply to this patient:
disturbed growth
From the list, mark all that apply to this patient:
deafness
From the list, mark all that apply to this patient:
reproductive problems
From the list, mark all that apply to this patient:
relaxed, laid back
From the list, mark all that apply to this patient:
sociable
From the list, mark all that apply to this patient:
round and large
From the list, mark all that apply to this patient:
loyal
From the list, mark all that apply to this patient:
serene and balanced
From the list, mark all that apply to this patient:
cares for others (Motherly)
From the list, mark all that apply to this patient:
diarrhea
From the list, mark all that apply to this patient:
constipation
From the list, mark all that apply to this patient:
loss of appetite
From the list, mark all that apply to this patient:
vomits
From the list, mark all that apply to this patient:
gum disease
From the list, mark all that apply to this patient:
weak muscles
From the list, mark all that apply to this patient:
overeats-obese
From the list, mark all that apply to this patient:
worries
From the list, mark all that apply to this patient:
obeys the rules
From the list, mark all that apply to this patient:
aloof
From the list, mark all that apply to this patient:
loves order
From the list, mark all that apply to this patient:
disciplined attitude
From the list, mark all that apply to this patient:
symmetrical body
From the list, mark all that apply to this patient:
good haircoat
From the list, mark all that apply to this patient:
asthma
From the list, mark all that apply to this patient:
dry skin
From the list, mark all that apply to this patient:
sinus problems
From the list, mark all that apply to this patient:
nose problems
From the list, mark all that apply to this patient:
cough
Submit