Javascript must be enabled for the correct page display
Hours & Contact
Mon - Fri: 7 am - 7 pm
Sat: 7 am - 5 pm
Sun: 8 am - 5 pm
(760) 456-9556
Email Us
195 N. El Camino Real
Encinitas, CA 92024
facebook
twitter
instagram
youtube
google
google
google
Menu
Services
Cat Services
Cat Acupuncture
Cat Emergency Care
Cat Behavior
Cat Boarding
Cat Heartworm
Cat Deworming
Cat Anesthesia
Cat Cancer
Cat Dental Care
Cat Dermatology
Cat Diagnostic Imaging
Cat Flea & Tick
Cat Lab Tests
Cat Laser Therapy
Cat Medication
Cat Microchipping
Cat Nutrition
Cat Preventive Care
Cat Senior Care
Feline Osteoarthritis
Cat Spay & Neuter
Cat Surgery
Cat Vaccinations
Cat Wellness Exams
Kitten Care
Kitten Wellness Package
Dog Services
Dog Acupuncture
Dog Deworming
Dog Wellness Exams
Dog Pain Management
Dog Parasites
Dog Emergency Care
Dog Bathing & Hygiene
Dog Boarding
Dog Allergies
Dog Behavior
Dog Cancer
Dog Dental Care
Dog Diagnostic Imaging
Dog Fleas & Ticks
Dog Heartworm
Dog Lab Tests
Dog Laser Therapy
Dog Microchipping
Dog Nutrition
Dog Preventive Care
Dog Senior Care
Canine Osteoarthritis
Dog Spay & Neuter
Dog Surgery
Dog Vaccinations
Puppy Care
Puppy Wellness Package
General Services
Laboratory
Pain Management
Preventative Care
Surgery
Emergency Medicine
Health Span Wellness Appointment
Bathing
Boarding
Complementary Medicine
Dentistry
Diagnostic Imaging
About Us
Our History
Veterinarians
Staff
In The News
Press
Careers
Good Dog! Drake
Kids and The Drake Center
Our Community Involvement
Why AAHA?
Encinitas Community City Page
Blog
Resources
Forms
Pet Loss and Grief Support
Helpful Websites for Pet Owners
Video Center
Newsletter Archives
Breeds
Dogs
Cats
Client Handouts
Cats
Dogs
General
New Clients
Contact Us
Book Appointment
Search
Traditional Chinese Veterinary Medicine (TCVM) History Intake Form
Pet owner's name
Pet's name
Owner's Name
Owner's Email
Breed
Sex
- Select -
Male
Female
Transgender
Age
Primary concerns
Please rank in order of importance and now how long it has been a problem (i.e., diarrhea x 1 month).
Prior treatments attempted and outcome
If you are a new client, please also supply a copy of your pet's records before the appointment.
Any other prior illnesses, attempted treatment and outcome
Please supply a copy of your pet's records if these illnesses were treated at a different veterinary facility.
Have any similar problems been noted in your pet's littermates?
- None -
Yes
No
Unsure
Please describe
What is your pet's normal diet?
Please list all diets fed within the last year and how long the pet stayed on each diet.
How much do you feed your pet?
Is your pet's diet supplemented with any nutraceuticals, vitamins, herbs, or enzymes?
- None -
Yes
No
Unsure
Please list all supplements given within the last year and how long they pet stayed on each supplement.
Does your pet receive any human food on a regular basis?
- None -
Yes
No
Unsure
Please describe
When was your pet's diet last changed and what was the effect?
Are there any foods your pet does not tolerate well?
- None -
Yes
No
Unsure
Please describe
Has your pet's appetite changed?
- None -
Yes
No
Unsure
How?
Has your pet lost or gained weight?
- None -
Yes
No
Unsure
How much?
Over what length of time did the weight change occur?
Has your pet experienced any adverse side effects to medication in the past?
- None -
Yes
No
Unsure
Please describe
Does your pet seek heat or cold?
- None -
Heat
Cold
Neither
For example, does your pet prefer to lie on a cool floor or does he/she prefer a warm bed? Does your pet lay in the sun or in the shade?
Does your pet pant excessively?
- None -
Yes
No
Unsure
What time of day does the panting most frequently occur?
Is your pet experiencing pain?
- None -
Yes
No
Unsure
Where is the pain located an how long has it been present?
Is the pain worse at a particular time of day or in certain seasons?
Does the pain move from one area of the body to another?
Is your pet energetic?
- None -
Yes
No
Unsure
Does your pet have good stamina?
- None -
Yes
No
Unsure
Is your pet hyper-responsive to noise?
- None -
Yes
No
Unsure
Does your pet experience anxiety?
- None -
Yes
No
Unsure
What time of day does the anxiety occur?
Does your pet experience fearfulness?
- None -
Yes
No
Unsure
Does your pet experience aggression toward people?
- None -
Yes
No
Does your pet experience aggression toward other dogs?
- None -
Yes
No
Does your pet experience confusion?
- None -
Yes
No
Unsure
Does your pet ever experience tremors, such as involuntary shaking of the leg or head?
- None -
Yes
No
Unsure
Is your pet lethargic or quiet?
- None -
Yes
No
Unsure
Are there changing trends in your pet's behavior?
- None -
Yes
No
Unsure
Please describe
Is your pet's thirst normal?
- None -
Yes
No
Unsure
Has your pet's thirst changed?
- None -
Yes
No
Unsure
Has there been any change in your pet;s urination?
- None -
Yes
No
Unsure
Does your pet experience any straining with urination?
- None -
Yes
No
Unsure
Does your pet experience any incontinence (urine leaking)?
- None -
Yes
No
Unsure
What time of day does the incontinence occur?
Does your pet vomit?
- None -
Yes
No
Unsure
How often does the vomiting occur?
How long after eating does the vomiting occur?
What is the consistency of the vomit? Please select all that apply
Food
Clear fluid
Yellow fluid
Green fluid
Are your pet's bowel movements normal?
- None -
Yes
No
Unsure
What is the consistency of the bowel movement? Please select all that apply
Rocks
Chalky
Soft tubes
Cow patties
Pudding
Syrup
Water
How many times per day does your pet make a bowel movement?
Does your pet have accidents in the house?
- None -
Yes
No
Unsure
What time of day do the accidents occur?
Does your pet experience constipation?
- None -
Yes
No
Unsure
Is there blood or mucus in your pet's stool?
- None -
Yes
No
Unsure
Does your pet experience flatulence?
- None -
Yes
No
Unsure
Does your pet sleep soundly through the night?
- None -
Yes
No
Unsure
When does the waking occur?
Have your pet's sleeping pattern changed?
- None -
Yes
No
Unsure
Does your pet dream frequently?
- None -
Yes
No
Unsure