IMPORTANT: Please answer all questions and use text boxes to elaborate on questions where more than one choice may apply. |
Correct Form Confirmation (required) :
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My pets TCVM appointment request is via the following branch of Dr. Browns practice: (required) :
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Email address (required)
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Patient Name (required)
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Species :
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Main Concerns
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TCVM Treatment Goals
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Start of Symptoms
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Duration of Symptoms
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Frequency of Symptoms
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Pattern of Symptoms i.e. time of day, specific time or hour, etc.
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Seasonality of Symptoms :
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My pet is taking the following medications
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My pet is taking the following supplements
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My pets diet is: :
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Additional diet comments
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My pets energy level is: :
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Additional energy comments if multiple choices apply
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My pets behavior is: :
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Additional Behavior Comments if multiple choices apply
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My pets sleep is: :
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Location of my pets sleeping
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Temperature Preference of Pet: :
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Additional Temperature Comments if multiple choices apply
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Appetite :
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Additional Appetite Comments
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Thirst :
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Additional Thirst Comments
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Stool :
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Additional Stool comments
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Urine :
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Additional Urine Comments
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Vomiting :
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Additional Vomiting Comments
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Cough :
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Additional Cough Comments
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Pain/Stiffness :
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Additional Pain/Stiffness Comments
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Breathing :
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Additional Breathing Comments
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Exercise :
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Additional Exercise Comments
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Petting/Massage :
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Additional Petting Comments
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Allergies :
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Additional Allergy Comments
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Level of Itchiness :
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Location (s) of Itchiness
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Season of Allergies :
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Additional Comments
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Five Element Theory & Personality |
Fire Element (Heart/Pericardium)
BALANCED: Lively, Communicative/Vocal, Very Friendly, Affectionate, Loves to be petted, Center of party
UNBALANCED: Separation Anxiety, Heart Disease, Insomnia, Thunderstorm Phobia, Restlessness, Fever, Excessive Panting |
My pet has the following Fire Element Traits and/or Concerns
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Earth (Spleen/Stomach)
BALANCED: Relaxed, Laid Back, Sociable, Round and Large, Loyal, Serene and balanced, Cares for others (motherly)
UNBALANCED: Loss of Appetite, Constipation, Diarrhea, Vomiting, Overweight, Gingivitis, Weak Muscles, Muscle Atrophy, Anxiety |
My pet has the following Earth Element Traits and/or Concerns
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Metal (Lung/Large Intestine)
BALANCED: Loves order, obeys rules, aloof, symmetrical body, disciplined attitude, good haircoat
UNBALANCED: Coughing, Breathing Concerns, Sneezing, Nasal Discharge, Nose problems, Dry Skin and Coat, Weak bark or voice, Asthma, Sinus problems |
My pet has the following Metal Element Traits and/or Concerns
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Water (Kidney/Bladder)
BALANCED: Careful, Curious, Self contained, Likes to hide, Meditative, Slow and consistent
UNBALANCED: Urinary disease or urinary concerns, Arthritis, Back Pain, Limping, Rear
End Weakness, Fearful, Deaf, Reproductive concerns, Ear Disease, Ear Infections, Dental disease or Teeth concerns |
My pet has the following Water Element Traits and/or Concerns
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Wood (Liver/Gallbladder)
BALANCED: Decisive, Assertive, Confident, Strong, Impulsive, Athletic stamina, Alpha
UNBALANCED: Liver disease, Tendon/Ligament or Joint Disease, Eyes, Ears, Dry or cracked nails or hooves, Aggression, Behavior Concerns, Seizures |
My pet has the following Wood Element Concerns
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I believe my pet has the following TCVM Five Element Personality (required) :
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Additional TCVM Five Element Personality Comments
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I understand alternative healing modalities may supplement and improve my pets wellbeing but do not necessarily replace conventional medicine
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I understand that although rare risks may include drowsiness, incontinence, infection, broken needles under skin, needle ingestion or bleeding
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I understand all TCVM appointments include acupuncture and that additional fees apply for adjunct or a la carte services such as Chinese Herbal Medicine and Food Therapy
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I authorize Dr. Brown to perform alternative therapies on my pet including but not limited to Traditional Chinese Veterinary Medicine Acupuncture, Herbal Medicine and Food Therapy if recommended and agreed upon during appointment time
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Equine Acupuncture 
