Integrative Medicine Form

Veterinarian Information

Name*

Practice*

Address*

Telephone

Email*

Patient Information

Name*

Species*

Sex*
Male     Female     Intact    

Age

Weight*

Current Medication*

Major Complaints

Current Food/Diet

Assessment

Temperature Preferences
Warm     Cold

Femoral Pulses
Strong     Weak     Deep     Thready

Tongue

Pallor
Red     Purple     Pale

Moisture
Wet     Dry

Texture/Coating
Overflowing     Cracked     Greasy     Yellow    

Fire

Normals
Lively
Communicative
Very Friendly
Affectionate
Loves to be Petted
Center of the Party

Abnormals
Insomnia
Separation Anxiety
Restless
Excess Heat
Rapid Heart Rate
Heart Problems

Wood

Normals
Decisive
Assertive
Confident
Strong
Impulsive
Athletic-Stamina
Alpha Animal

Abnormals
Ligament Problems
Liver Problems
Red Eyes
Angers Easily
Ear Problems
Nail Problems
Footpad Problems
Anal Sac Issues

Earth

Normals
Relaxed, Laid Back
Sociable
Round and Large
Loyal
Serene and Balanced
Cares for Others (Motherly)

Abnormals
Diarrhea
Constipation
Loss of Appetite
Vomits
Gum Disease
Weak Muscles
Overeats-Obese
Worries

Water

Normals
Careful
Curious
Self Contained
Likes to Hide
Meditative
Slow and Consistent

Abnormals
Rear Weakness
Fearful
Bone and Back Issues
Urinary Problems
Disturbed Growth
Deafness
Reproductive Problems

Metal

Normals
Loves Order
Obeys the Rules
Aloof
Symmetrical Body
Disciplined Attitude
Good Haircoat

Abnormals
Asthma
Dry Skin
Sinus Problems
Breathing Disorder
Nose Problems
Cough

Scheduling

Please provide your preferred day(s) and time(s) for scheduling this 20-minute appointment with the Integrative Medicine service at NorthStar VETS. A member of this team will contact you with further details.
Tuesday
Wednesday
Thursday
Friday

Morning (9am-11am)
Midday (11am-2pm)
Afternoon (2pm-5pm)

Check the box below