Acupuncture Consultation

1
Owner Information* This field is required.
Your First Name
Your Last Name
Please enter your email
2
Pet’s Name* This field is required.
3
Date* This field is required.
Date
Year
Month
Day
4
How is your pet’s appetite?
5
Please describe your pet’s bowel movements, including the presence of any blood or mucous.
6
Any problems with gas? Vomiting?
7
Any coughing?
YESNO
8
If yes, describe the cough.
9
Is your pet thirsty?
YESNO
10
If yes, is it usually a large volume at one time or smaller sips?
11
How is the energy level?
12
Is there a preference for cool or warm places to lie down and sleep?
13
Any trouble falling or staying asleep?
14
How would you describe his/her overall emotional state?
15
What are your goals for your pet (i.e., what do you want us to accomplish with treatment)?
Should be Empty: