TCVM Virtual Consultation Intake Form Dr. Christopher Shapley, DVM, CVA, CVCH, CVFTTraditional Chinese Veterinary Medicine & Integrative Care Pet Information Pet's Name * First Name Last Name Species * Breed * Age * Sex * Female Male Spayed / Neutered * Yes No Weight * Primary Veterinarian * (Name/clinic) How did you hear about us? Advertisement Referral Social Media Other Pet Parent Information Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred contact method * Phone Email Text Reason for Consultation What are your main concerns for your pet? * (Please describe symptoms, behaviors, or diagnoses) Pet's Current & Past Medical History Current diagnoses * (from primary veterinarian) Surgeries, injuries or trauma * (past & present) Any chronic issues? * (skin, digestion, mobility etc.) Current medications, supplements, or herbs * (including dose, frequency, and duration) Diet & Appetite What is your pet currently eating? * (Include brands, proteins, homemade, treats, etc.) Appetite * Normal Increased Decreased Water Intake * Normal Increased Decreased Energy & Behavior Energy level * Normal Low High Temperament * Calm Anxious Aggressive Fearful Other Activity/exercise level * Notable behavior changes * Urination & Defecation Urination * Normal Increased Decreased Accidents Defecation Frequency * Defecation consistency * Normal Loose Hard Mucous Blood Any issues like straining, odor, or color changes? * Tongue & Pulse (if possible) Optional: If you're able to take a clear photo of your pet's tongue, please attach it to this form or email it prior to the appointment. Tongue appearance (Color, moisture, coating, shape) Pulse (if you've been taught how to check) TCVM-Specific Details Do symptoms worsen during a particular season or time of day? * Is your pet sensitive to cold, heat, dampness, or wind? * Does your pet seek cool areas, warmth, or avoid certain environments? * Additional Notes or Observations Anything else you'd like Dr. Shapley to know? Agreement By submitting this form, I acknowledge this is a virtual integrative consultation and that Dr. Shapley's role is complementary to my pet's primary veterinarian. I understand this does not replace urgent/emergency care. * Name * First Name Last Name Date * MM DD YYYY Thank you!
