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Client Login
For Veterinarians
CRCG TCVM Questionnaire
Client Name
(Required)
First
Last
Pet Name
(Required)
Pet name
1. What are you hoping Traditional Chinese Veterinary Medicine will accomplish for your pet?
(Required)
2. What is your pet's energy level?
(Required)
3. Is your pet's appetite:
(Required)
Normal
Decreased
Increased
4. Are your dog's stools:
(Required)
Normal
Abnormal
If your dog's stools are abnormal, describe what they look like.
5. Is your pet coughing?
(Required)
Yes
No
If your pet is coughing, describe the cough.
6. Is your pet sneezing?
(Required)
Yes
No
7. Is your pet vomiting?
(Required)
Yes
No
8. Is your pet's water intake:
(Required)
Normal
Increased
Decreased
9. Is your pet's urination:
(Required)
Normal
Increased amount
Decreased amount
Bloody
10. Is your dog:
(Required)
Heat seeking
Warm seeking
Neutral
11. Does your dog sleep through the night?
(Required)
Yes
No
If not, describe what happens.
12. Describe your pet's behavior around stranger pets.
(Required)
13. Describe your pet's behavior around humans.
(Required)
14. Is your pet itchy?
(Required)
Yes
No
If yes, where?
15. Is your pet reactive to loud noises?
(Required)
Yes
No
16. Is your pet reactive to sudden movement?
(Required)
Yes
No
17. Does your pet have a history of seizures?
(Required)
Yes
No
18. Does your pet have a history of heart disease?
(Required)
Yes
No
19. What is your pet's diet?
(Required)
20. What medication(s) is/are your pet taking?
(Required)
21. What supplement(s) is/are your pet taking?
(Required)
Comments
This field is for validation purposes and should be left unchanged.