Acupuncture Form (Part 2)
Exercise
Exercise
Walks: Every day
Walks: Two to three times a week
Walks: Occasionally
Exercise is limited to the yard
Visits dog park
Does not go for walks, but exercises by
Cannot exercise, because of health issues
Does not have the stamina that it used to
Visits dog park – How often?
Does not go for walks, but exercises by
Urination
Urination
*
Urination habits have not changed
Urination habits have changed
Urinates more frequently
Urinates less frequently
Has accidents in the house
Strains to urinate
Urine color or odor is different
If urine color or odor is different, please describe
Defecation / Stool
Defecation
Bowel habits have not changed
Bowel habits have changed
Stool is usually normal
Stool is often soft
Stool is often loose/diarrhea
Strains to defecate
Has accidents in the house
Mucus in stool
Blood in stool
Passes gas frequently
How often does your pet have soft stools or diarrhea?
Please Select
Rarely
Once a month
Once a week
Several times a week
Daily
Loose/soft stools occur mostly
Please Select
In the morning
In the afternoon
In the evening
Overnight
No particular time
Vomiting
Vomiting
*
Does not vomit
Vomits occasionally
Vomits frequently
Vomits only with certain foods/treats
Vomits on an empty stomach
If your pet vomits, how often?
Please Select
Less than once a month
1–3 times per month
1–3 times per week
Daily
Multiple times per day
Vomiting occurs mostly
Please Select
In the morning
In the afternoon
In the evening
Overnight
No particular time
Vomiting – Abdominal effort
Little effort, mostly regurgitation
Moderate abdominal effort
Strong abdominal heaving
Contents of vomit
Food
Bile (yellow fluid)
Foam
Grass
Hairballs
Blood
Vomiting – Comments
Respiration / Breathing
Respiration
Breathing appears normal
Breathing is sometimes labored
Breathing is often labored
Pants only when hot or after exercise
Pants frequently, even at rest
Pants at night
Open-mouth breathing (for cats)
Loud breathing pattern
Noisy breathing
Snoring
Snorting
Grunting
Wheeze
No wheeze
Wheezes occasionally
Wheezes frequently
Cough – timing and triggers
Does not cough
Coughs occasionally
Coughs frequently
Coughs at night
Coughs after exercise
Coughs when excited
Coughs when drinking/eating
Cough – character
Dry, hacking cough
Moist, productive cough
Gagging or retching with cough
“Honking” cough
Referral Clients – Past Health Issues
Past Health Issues
*
Arthritis / joint disease
Hip dysplasia
Back problems / IVDD
Neurologic disease / seizures
Heart disease
Kidney disease
Liver disease
Endocrine disease (e.g., Cushing’s, diabetes, thyroid)
Cancer / tumors
Skin allergies / chronic skin disease
Chronic ear infections
Chronic gastrointestinal issues
Previous surgeries (specify below)
Other significant past health issues
Please describe any other past health issues or provide details about previous surgeries
Submit
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