Acupuncture Questionnaire and Consent Form Final

Acupuncture Questionnaire and Consent Form

An acupuncture request will be provided by your TC Rehab doctor, but to better understand your pet's complete health and well-being we ask that you please answer the following questions so that Dr. Whaley can tailor an acupuncture protocol specifically for your pet.
Owner's Full Name*
Pet's Name*
Pet's Age*
Species:*

CatDog
Primary reason for visit:*
Medications and Supplements

*Please include any new medications or supplements prescribed by TC Rehab*
Please list all medications your pet currently takes (including any monthly parasite preventives):*
Please list all supplements or herbal remedies your pet currently takes:*
Is your pet currently receiving any of the following therapies?

chiropractic/spinal manipulationprofessional massagecold laser therapyhydrotherapy
Body Systems Review

I. Mobility
My pet has lameness of the following limbs:

Left frontRight frontLeft hindRight hind
My pet's mobility is:*

NormalDecreased
My pet has difficulty with:

Sitting/lying downGetting up from restStairsGetting on/off furnitureWalkingRunningPosturing to go to the bathroomGetting in/out of litterboxOther (please specify):
II. Pain
On a scale of 0 to 10 (0 being no pain, 10 being the worst pain), my pet's average level of pain over the last month is: enter score here* out of 10
My pet's pain is worst:

After restAfter activityIn the morningIn the eveningSpecific activities cause my pet pain (please list):
III. Gastrointestinal
My pet's appetite is:*

NormalIncreasedDecreasedPicky eater
My pet's water intake is:*

NormalIncreasedDecreased
Please check all conditions that commonly apply to your pet:

Nausea/vomitingDiarrheaConstipationBlood or mucus in stoolsGassinessFecal incontinence
IV. Urinary
Please check all that apply:

Urinary incontinenceUrine leakingInability to fully urinate or needs assistance (bladder expression) to urinateRecurrent urinary tract infectionRenal disease/renal failure
V. Cardiovascular
Please check all that apply:

Heart murmerHeart arrythmiaHeart failureHigh blood pressureLow blood pressureMy pet has a pacemakerMy pet has a history of bleeding/clotting disorder
VI. Respiratory
Please check all that apply:

CoughingSneezingNasal dischargeChange in voice/vocalizationsLaryngeal paralysisPanting when not exercisingIncrease respiratory effort after normal activityTracheal collapseAsthma
VII. Neurologic

Has your pet ever been diagnosed with any of the following?
Seizures:*

YesNo
How frequent are the seizures?
How long do the seizures last?
When is the date of the last seizure?

MonthDayYear
Date
Please describe your pet's seizures:
Other conditions:

Geriatric Onset Laryngeal Paralysis Polyneuropathy (GOLPP)Degenerative myelopathy (DM)Vestibular diseaseCognitive dysfunction/dementiaStrokeMeningitisLimb weakness, dragging, or knuckling (please describe):
VIII. Endocrine
Has your pet been diagnosed with any of the following:

Thyroid diseaseDiabetesCushings (hyperadrenocorticism)Addisons (Hyporadrenocorticism)
X. Immune System
Has your pet been diagnosed with any of the following?

Immune mediated joint diseasesImmunosupressionImmune mediated anemia (red cell destruction) or thrombocytopenia (platelet destruction)
Allergies:

Skin allergiesFood allergiesEnvironmental allergies
Are the allergies:

SeasonalYear-roundAfter eating certain foods
If known, what is your pet allergic to?
Has your pet ever been diagnosed with or treated for cancer?*

NoYes (please specify type of cancer, where it occured on the body, and what, if any, surgeries or treatments were done:
XI. Behavior/personality
My pet is:

HappyDepressedCalmExciteableFearfulShyNervousRestlessReactive toward unfamiliar peopleReactive toward unfamiliar animals
Is there any other specific information you would like us to know regarding your pet's behavior that may help make visits less stressful for your pet?
XII. Other
Does your pet have any of the following:

Dental disease or painEye issues (including cataract. dry eye, or vision loss)Changes in hearing/hearing lossDoes your pet have any skin wounds or infections, if so please specify where on the body and how you are treating/managing it:
Has your pet had any previous surgeries (not including spay/neuter)? If so, please specify:
Is your pet overly sensitive to having their feet handled?*

YesNoSometimes
Is there any other medical information you would like to share regarding your pet's health?
I have answered the above to the best of my knowledge and made known all health issues my pet has. I have read the FAQ information provided, and have had any additional questions answered to my satisfaction by TC Rehab. I consent to my pet receiving acupuncture and understand potential risks and side effects.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: