ACUPUNCTURE QUESTIONNAIRE

Pet's Name *

Have we seen your pet here at Dundas West Animal Hospital before?

Yes
No
Unsure

What species is your pet?

Is your pet:

What breed is your pet?

What colour is your pet?

What is your pet's birth date or estimated age?

Is there another veterinary clinic that we can contact to obtain a copy of your pet's medical records?

How did you hear about and choose our clinic?

What are the main health problems that your pet is experiencing?*

Do any of these problems happen regularly at the same time of day? If YES, what time of day?

How long have these problems been present?

Which conditions or activities cause these problems to worsen?

Does your pet prefer warm or cool places, or neither? Please describe

Has your pet shown any behavioral, personality, or temperament changes recently?

Yes
No
Unsure

If yes, please describe:

What kinds of commercial food, human food, and treats does your pet regularly eat?

Please list all medications or supplements that your pet is currently receiving

Which of these words (if any) best describe your pet when (s)he is healthy and feeling well? (Question 1 of 5)

Which of these words (if any) best describe your pet when (s)he is healthy and feeling well? (Question 2 of 5)

Which of these words (if any) best describe your pet when (s)he is healthy and feeling well? (Question 3 of 5)

Which of these words (if any) best describe your pet when (s)he is healthy and feeling well? (Question 4 of 5)

Which of these words (if any) best describe your pet when (s)he is healthy and feeling well? (Question 5 of 5)

Has your pet had any vomiting? If yes, please describe:

Has your pet had any diarrhea? If yes, please describe:

Has your pet had any change in drinking or urination quantities? If yes, please describe:

Has your pet had any excessive itching or scratching? If yes, please describe:

Has your pet had any coughing or sneezing? If yes, please describe:

Has your pet experienced any lameness? If yes, please describe:

Does your pet have any lumps or bumps? If yes, please describe

How well does your pet sleep through the night?

Normal
Difficulty falling asleep/restless, takes a long time to settle
Frequently waking up in the night

How is your pet's appetite?

How are your pet's energy levels?

What are your goals for your pet's treatment with Acupuncture and Traditional Chinese Veterinary Medicine?*

What treatments have been tried previously for your pet's current health concern?

Have any diagnostic tests been performed related to your pet's current health concern?

Yes
No

If yes, what diagnostic tests have been performed, and at which clinic(s)?

Security Question *

ACUPUNCTURE QUESTIONNAIRE

Which practice would you like to register with?

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