New Acupuncture Patient
Pet Name
First Name
Last Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Species
Please Select
Canine
Feline
Exotic
Sex
Please Select
Male
Male Neutered
Female
Female Spayed
What is your main reason for seeking / needing acupuncture
Health Problems (please describe below)
General Wellness
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:
Normal
Reduced
Increased
Energy is highest:
Morning
Afternoon
NIght
Consistent
Attitude/mood is best:
Morning
Afternoon
Night
Consistent
My pet is
outgoing
Shy
Agressive
My pet is
Happy
Content
Restless
Crabby
Depressed
My pet prefers:
To be cool
To be warm
No preference
Sleep:
Normal
Decreased
Increased
Restless at night
Dreams:
None
Vocalization
Running
Mobility
Mobility Levels:
Normal
Reduced
Increased
Mobility is best
Morning
Afternoon
Night
Consistent
My pet has a specific area that is weak or lame:
Yes
NO
If yes please circle all that apply
Front right leg
Front left leg
Back right leg
Back left leg
Pain
My pet is in pain:
Yes
No
Pain is ____/10 (10 is worst)
If yes how long:
After rest pain is:
Better
Worse
After exercise pain is:
Better
Worse
Weather/temperature effects pet's pain?
Yes
No
Pain is better in:
Morning
Afternoon
Night
No difference
Nutrition / Digestion/Urinary
Appetite:
Normal
Increased
Decreased
My pet:
Loves to eat
is not food motivated
is picky
Vomiting
none
occasional
couple times weekly
Please describe vomiting if frequent.
Check all that apply with stools:
Normal
Constipation
Mucous
Strong odor
Soft
Incontinent
Neurological
Gas
Diarrhea
Blood
No odor
Hard/Dry
Other
Thirst?
normal
Increased
Decreased
Water intake?
frequent small sips
large amount at one time
Normal
Check all that apply with urine?
normal
Increased
Decreased
incontinent
Straining
Vocalizes
strong odor
dark yellow
clear
Skin
My pet has:
Brittle nails
Dry pads
Dry skin, large flakes
Dry skin small flakes
If your pet itchy?
Yes
NO
When is your pet itchy?
sometimes
during day
At night
All the time
Has your pet's hair coat changed?
Yes
NO
Breathing / Respiration
Check any that apply
cough
wheezes
normal
change in voice/noises
Submit
Should be Empty: