First Alternative Medicine Exam Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Yang Feaces: (massage): Owner Name *FirstLastPlease check any boxes below that apply to your petAddress *EmailPet's Name *BreedAge (years) *Age (months)Sex *— Select Choice —Male EntireMale NeuteredFemale EntireFemale NeuteredCurrent MedicationMajor complaints Current Diet / Food Please check any boxes below that apply to your pet below: Fire Normals livelycommunicativevery friendlyaffectionateloves to be pettedcentre of the partyFire Abnormal insomniaseparation anxietyrestlessexcess heatrapid heart rateheart problemsWood Normals decisiveassertiveconfidentstrongimpulsiveathletic-staminaalpha animalWood Abnormals ligament problemsliver problemsred eyesangers easilyear problemsnail problemsfootpad problemsanal sac issuesEarth Normalsrelaxed, laid backrelaxed, laid backround and largeloyalserene and balancedcares for others (motherly)Earth Abnormalsdiarrheaconstipationloss of appetitevomitsgum diseaseweak musclesovereats-obeseworriesWater Normalscarefulcuriousself containedlikes to hidemeditativeslow and consistentWater Abnormalsrear weaknessfearfulbone and back issuesurinary problemsdisturbed growthdeafnessreproductive problemsMetal Normalsloves orderobeys the rulesaloofsymmetrical bodydisciplined attitudegood haircoatMetal Abnormalsasthmadry skinsinus problemsbreathing disordernose problemscoughYang (Heat) / Yin (Cold) – Preference: Shade or cool locations (concrete/tile)Sun or warm locations (carpet)Please all select all the traits that apply to your pet. If you are unsure or your pet is “Normal” or “Neutral” leave the Yang/Yin item unchecked.Personality Hyperactive, outgoing, confident, strong (Fire/Wood)Quiet, timid less confident (Earth/Water)DietDry food, hot food (chicken, mutton, deer)Iced food or drink, cold food (fish, tofu), cold rawThirstThirstyLess ThirstyAppetiteRavenousFinickyFeacesDry or bloody or malodorousLoose or diarrhoeaUrineShort stream or malodorous or bloody urineLong stream or urinary leakageMedications Steroids, Yang/Qi tonic herbsAntibiotic, Heat-clearing/Yin Tonic herbsAgeYoung disease courseOldDisease Course ShortLong disease courseDisease CourseAcute diseaseChronic diseaseFURTHER QUESTIONS- Water intake: NormalLoves to drinkNo thirstIncreasedDecreasedTick all that apply Food Intake: NormalFinickyPoorRavenousVoice:LoudWeakChangedCough:WetLoudWeakProductive (foam/phlegm)Respiration:NormalHeavyStrongWeakSuperficialShort of breath on walksFeaces:NormalWateryLooseDryConstipationBloodyMucousIncontinentMalodorousUrination:NormalLongShortIncontinentBloodyMalodorousExercise:NormalLotsToo LittleIntolerant (quits or refuses)Sleep:NormalToo muchToo littleRestless at nightVocalizes at nightLikes Soft bed or Hard bedMuscle jerking during sleepVomiting:NoneFrequentSporadicAM/PMJust after eatingVomiting (volume):Much or LittleFood or water or bothWith undigested foodStiffness:AcuteChronicNoneStiffness (worse):In morningIn eveningWhen coldWhen hotWhen dampWith exerciseWhen first gets up then betterStiffness (massage):LikesDislikesSubmit Completed Form
