First Alternative Medicine Exam Form Owner InformationName(Required) Phone(Required)Email(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Animal InformationName Species Breed Sex Male Female Intact Yes Age Weight Current Medication Major Complaints Current Diet/Food TCM SurveyPlease check any boxes below that apply to your pet.FIREFire Normals lively communicative very friendly affectionate loves to be petted center of the party Fire Abnormals insomnia separation anxiety restless excess heat rapid heart rate heart problems WOODWood Normals decisive assertive confident strong impulsive athletic-stamina alpha animal Wood Abnormals ligament problems liver problems red eyes angers easily ear problems nail problems footpad problems anal sac issues EARTHEarth Normals relaxed, laid back sociable round and large loyal serene and balanced cares for others (motherly) Earth Abnormals diarrhea constipation loss of appetite vomits gum disease weak muscles overeats-obese worries WATERWater Normals careful curious self contained likes to hide meditative slow and consistent Water Abnormals rear weakness fearful bone and back issues urinary problems disturbed growth deafness reproductive problems METALMetal Normals loves order obeys the rules aloof symmetrical body disciplined attitude good haircoat Metal Abnormals asthma dry skin sinus problems breathing disorder nose problems cough Yang (Heat) and Yin (Cold)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.Yang (Heat)Yin (Cold)Preferences: Shade or cool locations (concrete/tile) Sun or warm locations (carpet) Personality: Hyperactive, outgoing, confident, strong (Fire/Wood) Quiet, timid less confident (Earth/Water) Diet: Dry food, hot food (chicken, mutton, deer) Iced food or drink, cold food (fish, tofu), cold raw Thirst: Thirsty Less Thirsty Appetite: Ravenous Finicky Feces: Dry or bloody or malodorous Loose or diarrhea Urine: Short stream or malodorous or bloody urine Long stream or urinary leakage Medications: Steroids, Yang/Qi tonic herbs Antibiotic, Heat-clearing/Yin Tonic herbs Age: Young disease course Old Disease Course: Short Long disease course Disease Course: Acute Disease Chronic Disease Further QuestionsWater Intake: Normal Loves to drink No thirst Increased Decreased Food Intake: Normal Finicky Poor Ravenous Voice: Loud Weak Changed Cough: Wet Loud Weak Productive (foam/phlegm) Cough Daytime Nighttime Worse at night Respiration: Normal Heavy Strong Weak Superficial Short of breath on walks Feces: Normal Watery Loose Dry Constipation Feces: Bloody Mucous Incontinent Malodorous Urination: Normal Long Short Incontinent Bloody Malodorous Exercise: Normal Lots Too little Intolerant (quits or refuses) Sleep: Normal Too much Too little Restless at night Vocalizes at night Sleep: Likes Soft bed or Hard bed Muscle jerking during sleep Vomiting: None Frequent Sporadic AM/PM Just after eating Vomiting (Volume): Much or Little Food or water or both With undigested food Stiffness: Acute Chronic None Stiffness (worse): In morning In evening When cold When hot When damp With exercise When first gets up then better Stiffness (massage): Likes Dislikes CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
