Name:

Address:

Primary Phone:

Email:

Name:

Species:

Breed:

Sex:

Birthdate/Age:

Does your pet have any fears or phobias?

Does your pet have any trouble falling asleep? Staying asleep?

Does your pet have active dreams?

Where does your pet sleep?

What is your pet’s diet? Dry kibble or canned food? Other? (Brand, variety, amount, how often) What is the main protein and carbohydrate source?

What treats and other food does your pet eat? How many and how often?

What type of exercise does your pet get?

(activity/frequency)

Describe your pet's appetite

(normal, increased, decreased, etc)

Describe your pet's thirst

(normal, increased, decreased, etc)

Describe your pet's stool

(frequency, appearance, volume, odor)

Describe your pet's urination

(frequency, appearance, volume, odor)

Does your pet experience vomiting or gas?

(frequency, description)

Does your pet cough?

(frequency, description)

Does your pet pant excessively?

(all the time? specific times of day?)

What medications is your pet currently taking? (list all name, dose strength, frequency, even if only once in awhile or as needed)

What supplements is your pet currently taking? (list all name, dose strength, frequency, even if only once in awhile or as needed)

Does your pet have chronic or intermittent pain? Where? Why? Does anything make it better or worse?

What are your pet’s current signs or symptoms?

Does your pet have any past history or medical conditions or surgery?

Does your pet have any aggression toward people or other animals?

What are your expectations for treatment of your pet with acupuncture and integrative medicine?

Is there any other information that you feel it is important for us to know to treat your pet?

Acupuncture Questionnaire

The Five Elements