• ACUPUNCTURE HISTORY FORM

  • Welcome to the world of Integrative Veterinary Medicine, the combination of Conventional (or Western) Modern Medicine and Traditional Chinese Medicine. You are about to fill out a medical history that far surpasses your past experiences. Some of these questions may be straight forward, and some may be a little "weird", to say the least. In Traditional Chinese Veterinary Medicine, clues to the body's health are everywhere; we just have to ask the correct questions.

    Please take the time to fill out this very LONG questionnaire to the best of your ability. It may be best to read the questionnaire, fill out the easier points and then observe your pet for the next couple of days to answer the more "obscure" questions. The more detailed and accurate your answer, the more accurate the Traditional Chinese Medical diagnosis will be, and therefore the more effective the treatment can be.

  • MEDICAL HISTORY FORM

  • Were your referred by someone for acupuncture?
  • Have you ever had an acupuncture treatment yourself?

  • INHERENT CONSTITUTIONS

  • In Traditional Chinese Medicine, individuals can be categorized to fit into one or two particular Elements. The state of an individual's health can be influenced by their "inherent" elemental status. An individual's inherent constitution influences the animal's body structure, health, emotions, and when exposed to the same stress factors, individuals of different constitutions will react in a different way, whether it is positively or negatively. When a constitution is in balance, there is harmony and health in the system. When unbalanced, there is disease. Check all that apply below for your pet so we can get a better idea of their inherent constitution.

  • FIRE

  • FIRE Characteristics

  • EARTH

  • EARTH Characteristics

  • WOOD

  • WOOD Characteristics

  • METAL

  • METAL Characteristics

  • WATER

  • WATER Characteristics

  • REST AND ACTIVITY LEVEL (CHECK ALL THAT APPLY)

  • Rest and Activity Level Options
  • How long does it take for your pet to get up?
  • Sleeping and Comfort Preferences

  • POSTURE, GAIT AND MOVEMENT (CHECK ALL THAT APPLY)

  • Posture, Gait and Movement Options

  • EXERCISE (CHECK ALL THAT APPLY)

  • Exercise Options

  • URINATION (CHECK ALL THAT APPLY)

  • Please take the time to observe your pet's behavior regarding elimination for the next few days in order to answer the following questions.
  • Urination habits and symptoms

  • DEFECATION (CHECK ALL THAT APPLY)

  • Defecation habits and stool quality
  • If pet intermittently has loose stools, how often is your pet having this issue?
  • What time of day do the abnormal bowel movements occur?
  • Other gastrointestinal symptoms
  • Date of recent fecal parasite screening (if known).
     - -
    2 digit month, 2 digit day, 4 digit year

  • VOMITING (CHECK ALL THAT APPLY)

  • Vomiting frequency and occurrence
  • How often is your pet vomiting?
  • What time of day is your pet vomiting?
  • What are the contents of the vomit?

  • RESPIRATION (CHECK ALL THAT APPLY)

  • Respiration Symptoms
  • Cough Characteristics
  • Date of Recent Thoracic X-rays (if applicable)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Recent Heartworm Test (if applicable)
     - -
    2 digit month, 2 digit day, 4 digit year

  • ENVIRONMENT AND LIVING SITUATION

  • General
  • Indoor/Outdoor Status
  • Yard Access
  • Location Type
  • Pet Compatibility
  • Pets were added to the household within the past:
  • Pets have been lost to the household within the past:
  • Recently and overall, my pet's attitude toward life, family and surroundings has been:

  • SKIN AND HAIR COAT (CHECK ALL THAT APPLY)

  • Skin and hair coat general status
  • Specific skin and hair symptoms
  • Where is your pet scratching? Check all that apply:
  • Flea/Tick Prevention

  • MENTAL STATUS AND VOCALZIATION (CHECK ALL THAT APPLY)

  • For those of you who work between 8 AM and 6 PM, it is difficult to answer some of the questions with specific times. Rely on your observations during your days off and on weekends. Unless there is a lot going on in the household, most pets will stick to their same schedules of behavior, even on the weekend.
  • Vocalization and play behaviors
  • Confusion and disorientation behaviors
  • Pet activity and happiness times

  • DIET

  • Dietary Preferences and Habits
  • What types of food do you feed your pet?
  • If you feed only human food, do you supplement with vitamins or minerals?
  • If you feed a raw diet of your own making, do you follow guidelines?

  • APPETITE AND DRINKING BEHAVIOR (CHECK ALL THAT APPLY)

  • Appetite and Drinking Behavior Options

  • CURRENT MEDICATIONS AND SUPPLEMENTS:

  • Current Medications & Supplements

  • TEMPERATURE / ENERGETICS:

  • YIN (EXCESS COLD)
  • YANG (EXCESS HEAT)
  • Should be Empty: