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.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 diarrhoea Voice: Normals Thirst UrineShort 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
