Patient Name: (required)
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Species: (required)
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Breed: (required)
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Date of Birth:
:
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Age: (required)
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Sex: (required)
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What is your patient’s main reason for seeking/needing acupuncture? (Specific Health Problems, General Wellness, etc) (required)
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If your pet was treated previously for this problem, please answer the following questions: |
What diagnostics have been done and what were the results? (ex. Bloodwork, X-rays):
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What treatments were utilized?
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Did the pet show any improvement? If so, please describe:
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Since your pet’s last veterinary visit, is he/she:
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Please list to your best ability: |
Current Medications: (required)
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Current herbs and/or supplements: (required)
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Current diet: (required)
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Current exercise regimen: (required)
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Traditional Chinese Medicine (TCM) history: (in each section, please check all that apply) |
Energy and Well-Being |
Energy level in general: (required)
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Energy is highest: (required)
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Attitude/mood is best: (required)
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My pet is: (required)
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My pet is: (required)
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My pet prefers: (required)
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Sleep: (required)
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Dreams: (required)
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Mobility |
Mobility level: (required)
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Mobility is best: (required)
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My pet has a specific area that is weak or lame: (required)
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If “Yes,” please check all that apply:
Front right leg
Front left leg
Back right leg
Back left leg
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Pain |
My pet is in pain: (required)
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If “Yes,” how long:
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If “Yes,” please complete the following regarding your pet’s pain |
Pain is _____/10 with 10 being the worst
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Is the pain in a specific area? Please explain if so:
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After rest is it:
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After exercise is it:
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How does weather/temperature affect your pet’s pain?
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Better in:
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Nutrition/Digestion/ Urinary |
Appetite: (required)
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My pet: (required)
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Vomiting: (required)
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If vomiting is a regular occurrence, please describe when it happens and what it looks like:
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Stools: (required)
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There is:
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Odor of stool: (required)
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Does your pet have gas? (required)
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Thirst: (required)
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Water intake: (required)
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Urine: (required)
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Color of urine? (required)
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Odor of urine? (required)
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Skin |
My pet has:
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Is your pet itchy? (required)
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If “Yes” please check all that apply:
Sometimes
During day
At night
All the time
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Has your pet’s hair coat changed? (required)
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Reproduction |
(required)
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Describe any reproduction problems your pet has had:
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Respiration/breathing: |
(required)
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If your pet has had a change in breathing, please describe:
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My pet’s voice or noises that he/she makes are: (required)
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If your pet's voice or noises have changed, please describe:
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Is there anything else we should know about your pet’s health or emotional history?
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