Patient Name
Chief Complaint
Previous Medical History
Current Medications / Supplements, including dosage
Any history of food or drug sensitivity? If yes, how?
Appetite: (i.e. normal, finicky, ravenous, etc, please explain)
Thirst: (i.e. normal, increased, temperature preference, please explain)
Hot vs Cold: (i.e. seeks sun / cool tile floor, sleeps under / above covers, etc, please explain)
Sleep: (i.e. energy in AM, dreaming, restlessness, snoring, etc, please explain)
Personality: (i.e. friendly, timid, fear aggressive, changeable temperament, noise sensitivity, etc, please explain)
Diarrhea? (i.e. mucus, blood, undigested food, color, odor, time of day, please explain)
Vomiting? (i.e. color, odor, undigested food, time of day, please explain)
Halitosis / Bloating / Gas? Please specify and explain.
Bladder Infections? (Strangurea, blood, treatment, please explain)
Incontinence? (time of day, worse after exercise, please explain)
Polyurea – production of abnormally large volumes of dilute urine? (color, odor, please explain)
Stamina / Shortness of breath? (effect of weather or exercise) please explain
Puritis: - severe itching of the skin (mild / severe, seasonality, please explain)
Discharge? (i.e. mild dandruff vs large flakes, effect of oil, moist / dry, please explain)
Otitis Externa: - inflammation or infection of the external auditory canal (i.e. odor, moist / dry, effect of season, puritis, please explain)
Ability to regrow hair?
Past Medications: (treatments / outcomes, please explain)
Stiffness / soreness? (Better with rest or movement, heat / cold, touch, please explain)
Lameness? (Better with rest or movement, heat / cold, touch, please explain)
Chronic pain / trauma? (Better with rest or movement, heat / cold, touch, please explain)
Eye discharge? (Color, mucus, moist vs dry, seasonality, medications, please explain)
changeable Vomiting? business
