TCVM Patient History Form

Brown Veterinary Housecalls

Mesa, AZ 85205


Brown Veterinary Housecalls  Equine Acupuncture  Soul Puppy Holistic Healing

TCVM Patient History Form

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Please note all required fields must be filled for form to process.

Please set aside a minimum of 20 to 40 min to complete form and be as detailed as possible. Thank you

TCVM Patient History Form

IMPORTANT: Please answer all questions and use text boxes to elaborate on questions where more than one choice may apply.
Correct Form Confirmation (required) :
My pets TCVM appointment request is via the following branch of Dr. Browns practice: (required) :
First Name (required)
Last Name (required)
Phone (required)
Phone TypePhone Number (required)
Email address (required)

Patient Name (required)

Species :
Main Concerns

TCVM Treatment Goals

Start of Symptoms

Duration of Symptoms

Frequency of Symptoms

Pattern of Symptoms i.e. time of day, specific time or hour, etc.

Seasonality of Symptoms :
My pet is taking the following medications

My pet is taking the following supplements

My pets diet is: :
Additional diet comments

My pets energy level is: :
Additional energy comments if multiple choices apply

My pets behavior is: :
Additional Behavior Comments if multiple choices apply

My pets sleep is: :
Location of my pets sleeping

Temperature Preference of Pet: :
Additional Temperature Comments if multiple choices apply

Appetite :
Additional Appetite Comments

Thirst :
Additional Thirst Comments

Stool :
Additional Stool comments

Urine :
Additional Urine Comments

Vomiting :
Additional Vomiting Comments

Cough :
Additional Cough Comments

Pain/Stiffness :
Additional Pain/Stiffness Comments

Breathing :
Additional Breathing Comments

Exercise :
Additional Exercise Comments

Petting/Massage :
Additional Petting Comments

Allergies :
Additional Allergy Comments

Level of Itchiness :
Location (s) of Itchiness

Season of Allergies :
Additional Comments

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

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

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

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

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

I believe my pet has the following TCVM Five Element Personality (required) :
Additional TCVM Five Element Personality Comments

I understand alternative healing modalities may supplement and improve my pets wellbeing but do not necessarily replace conventional medicine
I understand that although rare risks may include drowsiness, incontinence, infection, broken needles under skin, needle ingestion or bleeding
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
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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