NMC PATIENT RECORD FORM. Your Details Title...Mr/Mrs/Ms/Other First Name Surname Address. Telephone number Fax number E mail address
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1 NMC Natural Medicine Centre Richard Allport B.Vet. Med.,Vet.M.F.Hom., M.R.C.V.S. and Associates 11 Southgate Road ~ Potters Bar ~ Herts ~ EN6 5DR ~ U.K. Phone ~ Fax Your Details Title...Mr/Mrs/Ms/Other First Name Surname Address PATIENT RECORD FORM Telephone number Fax number E mail address Your Pet s Details Name Species...Dog/Cat/Other Breed Sex Colour Year of birth Age when neutered Main health problem Your Vet s Details Name of practice Address of practice Telephone number Fax number E mail address
2 Please put a tick or cross next to any of the statements which apply to your pet in the following information sections. Information about your pet s medical history Are any of the following conditions present now, or have they been in the past? Dry skin Abscesses Swollen glands Lumps or growths Liver disease Kidney disease Bladder disease Throat infections Dental trouble Back pain Arthritis Diabetes Anal gland trouble Fits cancer Paralysis Sinus trouble Ulcers Prostate disease Hernias Redness of eyes/nose/ears/lips Poor vision Going deaf Itchy ears Poor sense of smell Dry nose Nasal discharge Nose bleeds Dry lips Dandruff Dry cough Cough with mucus Chesty cough Loss of voice Weakened voice Sensitive skin Greasy skin/ears Cracked skin
3 Warts Scaly/peeling skin Itchy skin Legs/head twitch Swollen feet or legs Itchy feet Pain on urination Unpleasant smell to urine Sediment in urine Weak bladder Frequent urination Raw or sore genital area Sores or ulcers in mouth Dry mouth Excessive salivation Difficulty in swallowing Heart disease Poor circulation (For female pets) Lumps in mammary glands False pregnancy Itchy vulva Absence of seasons Heavy seasons Prolonged seasons Frequent seasons Discomfort during seasons Vaginal discharge Difficulty giving birth Difficulty feeding offspring Infertility Information about your pet s existing symptoms Are the symptoms: Worse in Autumn (Fall) Worse in Winter Worse in Spring Worse in Summer Worse in hot weather Worse in cold weather Worse in humid weather Worse at night Worse before midnight Worse after midnight Worse in mornings
4 Worse in afternoons Worse in evenings Worse intermittently Worse after sleep Better for sleep Worse with exercise Better with exercise Constantly changing On the right side of the body Going from right to left On the left side of the body Going from left to right Better for change of position Worse lying down Better lying down Worse lying on right side Worse lying on left side Worse when beginning to move Occurring slowly Occurring suddenly Better for heat Better for cold Worse for heat Worse for cold Information about when the problem began Did the main problem begin: After a vaccination After a shock After an injury After grief or bereavement After exposure to sun After treatment with prescription drugs After/during a season After/during a pregnancy Information about your pet s physical type Does your pet tend to: Be lethargic Be hyperactive Be underweight Be overweight Feel chilly
5 Feel hot Be sensitive to draughts Be sensitive to change in the weather Be worse in the open air Be better in the open air Like being covered by a blanket Hate being covered by a blanket Be very thirsty Have little thirst Be very hungry Be uninterested in food Vomit after food Have gurgling noises in stomach Suffer from wind Love certain foods Hate certain foods Often have constipation Sometimes have constipation Have bouts of diarrhoea Have watery faeces Have lumpy faeces Have dry, hard faeces Have black, tarry faeces Pass blood with faeces Strain when passing faeces Information about your pet s personality Does your pet tend to be: Nervous Irritable Restless Better when alone Better in company Apprehensive Unwilling to be touched or stroked Not enjoying life Stubborn Destructive Hysterical Aggressive to other animals Very sensitive to pain Frightened by sudden or loud noises
6 Other information What is your pet s basic diet What supplements (vitamins, minerals etc.) do you give regularly Do you know of any similar symptoms in any close relative of your pet Please note any other information you can think of Where did you hear about Richard Allport or the Natural Medicine Centre?
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