Acupuncture PATIENT Registration

Please complete the following questionnaire as completely as you can.

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Name

First

Last

Phone

Pet's Name

How was your pet acquired?

Describe your pet's typical day:

Please detail your pet's medical history:

Current diet:

Any dietary restrictions?

Can your pet have treats?

Current medications:

Major complaint and what we hope to improve with acupuncture?

Symptoms
If they are increased, decreased, or any other comments, please note

Voice:

For Example: Do they sound hoarse or raspy, are less vocal?

Activity Level:

Sleep

Does your pet sleep through the night? Do they wake up at any particular times during the night?

Temperature Preference:

Warm or cool places

Food Intake:

we about Activity

Water Intake:

Stool:

Urination

Vomiting:

Cough:

Stiffness:

Personality:

Please describe their typical personality. Are they very friendly? laid back? nervous etc.?

Has your pet ever received acupuncture before or are you familiar with Eastern Medicine?

Are you interested in exploring herbal medication and food therapy as an adjunctive treatment modality to acupuncture?