ZAW intake form

zenanimalwellness.com: 253-332-2237, Edgewood, WA 98372

Patient Name

Owner Name

1.What is your patient's main reason for seeking/needing acupressure?

Health Problem(s)-describe

General Wellness

2. If your pet was treated previously for this problem, please answer the following questions:

a What diagnostics have been done and what were results ex Bloodwork Xrays

b What treatments were utilized

C Did the pet show any improvement If SO please describe

d Since your pets last veterinary visit is he/she -The same/ Better/ Worse

3 Please list to your best ability

a Current Medications

b Current herbs and/or supplements

C Current diet

d Current exercise regimen

4. Traditional Chinese Medicine (TCM) history: (in each section, please cirlce all that apply)

a. Energy level in general: Normal/ Reduced /Increased

b. Energy is highest:Morning/Afternoon/Night/Consistent

c. Attitude/mood is best - Morning/Afternoon/Evening/Night/Consistant

d. My pet is -Outgoing/Shy/Aggressive

e. My pet is- Happy/Content/Restless/Crabby/Depressed

f. My pet prefers -to be cool/to be warm/Does not have a preference

g. Sleep- Normal/Decreased/Increased/ Restless at night

h. Dreams- None/Vocalization/Running

MOBILITY

a. Mobility level- Normal/Reduced/Increased

mobility is best- Mornings/Afternoons/Evenings/Night/Consistant

c. My pet has a specific area that is weak or lame:Yes / No

- If "Yes," please circle all that apply:

Front left leg /Front right leg

PAIN

My pet is in Pain

Yes/No

If Yes how long

If Yes please complete the following regarding your pets pain

I Pain is 10 with 10 being the worst

II. Is the pain in a specific area? Yes/No

III. After rest is it - Better/Worse

IV. After exercise is it: Better/Worse

V How does weather/temperature affect your pets pain

VI. Better in - Morning/Afternoon/Evening/Night/no time difference

NUTRITION/DIGESTION/URINARY

a. Appetite - Norma/Increased/Decreased

b. My pet - Loves to eat/ Is not food motivated/ Is picky

c. Vomiting - None/Occasional/A couple times a week/Often

If vomiting is a regular occurrence please describe when it happens and what it looks like

d. Stools - Normal/Soft/Diarrhea/Hard & dry/Constipation/Incontinent

- There is-Blood/Mucous in the stool

- Odor of stool - Normal/Stong/No odor

- Does your pet have gas? Yes/No

e. Thirst: Normal/Increased/Decreased

f. Water Intake - Frequent small sips/Large amounts at one time/Moderate

g. Urine - Normal/Increased/Decreased/Incontinent/Straining/Vocalizes

- color of urine- Normal/Clear/Dark Yellow

-odor of urine - Normal/no odor/strong odor

SKIN

a. My pet has: Brittle nails/ Dry pads/Dry Skin with large flakes/Dry Skin with small flakes

b. Is your pet itchy? - Yes/No

- If yes, please circle all that apply - Sometimes/During the day/At night/All the time

Has your pets hair changed? - No/Yes

If yes, please describe

Respiration/Breathing

a. Normal/Coughs/Has had a change in breathing

Describe

My pet's voice or noises that he/she makes are-The same/Have changed

Describe

5 Is there anything else we should know about your pets health or emotional history