New Client and Acupuncture Form
Thank you for giving us the opportunity to care for your pet(s)!
Full Name
*
First Name
Last Name
Spouse/Co-Owner (please include people qualified to make medical decisions for your pets)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Inside Jefferson City Limits? Y/N
*
Phone Number
*
E-mail
*
example@example.com
May we use, reuse, publish, and broadcast media of your pet? (pictures and videos)
*
Yes
No
How did you hear about us?
*
Please Select
Personal Recommendation
Clinic Website
Drove By
Internet
Other (Please specify...)
If personal recommendation (or other source), whom may we thank?
Back
Next
Acupuncture and Patient History Information
Pet's Name, Dog/Cat?, Age/Date of Birth?, Male/Female?, Spayed/Neutered?, Breed?, Color?
What is your pet's main reason for seeking/needing acupuncture?
Health Problem(s)? General Wellness? (please describe)
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)
What treatments were utilized?
Did the pet show any improvement? If so, please describe:
Since your pet's last veterinary visit, is he/she:
The same
Better
Worse
Please list to your best ability:
Current medications:
Current herbs and/or supplements:
Current diet:
Current exercise regimen:
Traditional Chinese Medicine (TCM) history:
In each section, please answer or circle all that apply.
Energy level in general:
Normal
Reduced
Increased
Energy is highest:
Morning
Afternoon
Night
Consistent
Attitude/mood is best:
Morning
Afternoon
Evening
Night
Consistent
My pet is:
Outgoing
Shy
Aggressive
My pet is:
Happy
Content
Restless
Crabby
Depressed
My pet prefers:
To be cool
To be warm
Does not have a preference
Sleep
Normal
Decreased
Increased
Restless at night
Dreams
None
Vocalization
Running
Back
Next
Mobility
Mobility Level:
Normal
Reduced
Increased
Mobility is best
Morning
Afternoon
Evening
Night
Consistent
Select all that apply if your pet has a specific area that is weak or lame:
Front right leg
Front left leg
Back right leg
Back left leg
Pain
My pet is in pain: Y/N- if yes, how long?
If you answered Yes, please complete the following regarding your pet's pain:
Pain is
blanks
/10 with 10 being the worst.
Is the pain is a specific area? Y/N- if yes, where?
After rest pet is
Better
Worse
After exercise pet is
Better
Worse
How does weather/temperature affect your pet's pain?
Pain better:
In AM
In afternoon
In evening
No time difference
Nutrition/ Digestion/ Urinary
What does your pet eat throughout the day? (please list food, treats, food from table, etc.)
Do you have total control over what your pet eats? (Kids or others in the house give more treats than you'd like?)
Yes
No
Appetite:
Normal
Increased
Decrease
My pet:
Loves to eat
Is not food motivated
Is picky
Vomiting:
None
Occasional
A couple of times per week
Often
Other
If vomiting is a regular occurrence, please describe when it happens and what it looks like:
Stools:
Normal
Soft
Diarrhea
Hard and dry
Constipation
Incontinent
Stools (select all that apply):
There is blood in stool
There is mucous in stool
Normal odor
Strong odor
No odor
Does your pet have gas?
Yes
No
Thirst
Normal
Increased
Decreased
Water Intake:
Frequent small sips
Large amounts at one time
Moderate
Urine
Normal
Increased
Decreased
Incontinent
Straining
Vocalizes
Color of urine:
Normal
Clear
Dark yellow
Odor of urine:
Normal
No odor
Strong odor
Skin
My pet has:
Brittle nails
Dry pads
Dry skin with large flakes
Dry skin with small flakes
Is your pet itchy? If yes, select all that apply:
Sometimes
During day
At night
All the time
Has your pet's hair coat changed? If yes, please describe:
Reproduction
Reproduction:
Fertile
Infertile
Not applicable (spayed/neutered)
Describe any reproduction problems your pet has had:
Respiration/ Breathing
If your pet's breathing is not normal, please describe the cough/ change in breathing:
My pet's voice or noises that he/she makes have changed: Y/N- if yes, please describe:
Is there anything else we should know about your pet's health or emotional history?
Submit
Should be Empty: