Acupuncture and Physical Therapy Questionnaire

1
* This field is required.
Client Name
Pet Name
Phone
Email
2
Has your pet ever had acupuncture?* This field is required.
YESNO
3
If so, date of last session and outcome.* This field is required.
4
Primary concern(s):* This field is required.What is your pet's primary concern/problem areas?
5
How long has this been a concern?* This field is required.
6
List all medications and supplements your pet is on* This field is required.If not applicable please put None.
7
List all foods/treats your pet eats* This field is required.
8
Describe your pet’s appetite, time of day he/she eats.* This field is required.
9
Is your pet a picky eater?* This field is required.
10
Have you noticed increased thirst?* This field is required.
YESNO
11
What are your pets drinking habits?* This field is required.
drinks a lot at once
drinks small amounts many times throughout the day
12
Temperature preference:* This field is required.
Shade or cool locations (tile, in front of AC vents)
Sun or warm locations (carpet, bedding)
13
Sleeping habits:* This field is required.
sleeps through the night
gets up and moves around through the night
has a hard time falling asleep
dreams frequently
Other
14
Other sleeping habits to note:* This field is required.
15
Stool Quality:* This field is required.
normal
dry/hard
bloody
malodorous
soft/loose
diarrhea
16
Urination Quality: * This field is required.
normal
short, frequent streams
bloody/malodorous
urinary leakage
long streams
increased frequency
17
Is your pet sneezing or coughing?* This field is required.
YESNO
18
If coughing or sneezing, please describe:* This field is required.
19
Has there been any vomiting?* This field is required.
YESNO
20
If vomiting, please describe:* This field is required.
21
Have there been any changes to your pet’s energy and/or stamina?* This field is required.
YESNO
22
If yes, please describe:* This field is required.
23
Describe your pet’s typical daily exercise/activity routine
24
Has there been a change in this routine? Explain
25
What is your pet’s personality? * This field is required.
bossy/aggressive
very friendly - runs up to play with other dogs/people
happy to play, but lets them come to him/her
doesn’t really care/aloof
timid/scared/runs away
26
* This field is required.
Is your pet patient?
Is your pet easily excited/startled? (Doorbell, loud noises)
Does your pet seem to like rules or “need a job”?
27
(For Dogs) How does your pet interact with other dogs?
28
How does your pet interact with other people?
29
Has your pet had any major illnesses, injuries, or surgeries in his/her lifetime?
30
Is there anything else I should know about your pet?
Should be Empty: