New Acupuncture Patient

New Acupuncture Patient
Pet Name

First NameLast Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Species
Sex
What is your main reason for seeking / needing acupuncture
What diagnostics have been done and what were the results? (blood work, x-rays)
What treatments have been utilized in the past?
Did your pet show any improvements? Is so please describe.
Please list current medications
Current supplements / herbs
Heartworm & Flea prevention
Current exercise regimen
Traditional Chinese Medicine (TCVM) History

Please check all that apply in each section
Energy & Wellbeing
Energy level in general:
Energy is highest:
Attitude/mood is best:
My pet is
My pet is
My pet prefers:
Sleep:
Dreams:
Mobility
Mobility Levels:
Mobility is best
My pet has a specific area that is weak or lame:
If yes please circle all that apply
Pain
My pet is in pain:
Pain is ____/10 (10 is worst)
If yes how long:
After rest pain is:
After exercise pain is:
Weather/temperature effects pet's pain?
Pain is better in:
Nutrition / Digestion/Urinary
Appetite:
My pet:
Vomiting
Please describe vomiting if frequent.
Check all that apply with stools:

Other
Thirst?
Water intake?
Check all that apply with urine?
Skin
My pet has:
If your pet itchy?
When is your pet itchy?
Has your pet's hair coat changed?
Breathing / Respiration
Check any that apply
Should be Empty:

Traditional Chinese Medicine (TCVM) History