District of Columbia
Zip / Post Code
Type of Pet
Pocket Pet (ferrets, guinea pigs, hamsters, etc...)
What is your pet’s main reason for seeking/needing acupuncture?
Health Problem(s) (describe below)
If health problem(s), please describe:
What diagnostics have been done and what were results? (ex. Bloodwork, X-rays)
What treatments were utilized (ex. surgery, physical therapy)
Did the pet show any improvement? If so, please describe:
Since your pet’s last veterinary visit, is he/she:
CURRENT HERBS AND/OR SUPPLEMENTS:
CURRENT EXERCISE REGIMEN:
Energy level in general – normal / reduced / increased
Energy is highest – morning / afternoon / night / consistent
Attitude/mood is best – morning / afternoon / evening / night / consistent
My pet is: Outgoing / Shy / Aggressive
My pet is: Happy / Content / Restless / Crabby / Depressed
My pet prefers: to be cool / to be warm / does not have a preference
Sleep – normal/decreased/increased/restless at night
Dreams – none/vocalization/running
Mobility level – normal / reduced / increased
Mobility is best – morning / afternoon / evening / night / consistent
My pet has a specific area that is weak or lame: yes / no (If “Yes,” please identify all that apply: Front right leg/Front left leg / Back right leg/Back left leg)
Is your pet in pain?
I'm not sure
Pain is ___/10 with 10 being the worst
Is the pain in a specific area? If yes, where?
Is the pain better or worse after rest?
Is the pain better or worse after exercise?
How does weather/temperature affect your pet’s pain?
Is your pet's pain better in morning/afternoon/evening or is there no time difference?
Is your pet's appetite normal/increased/decreased?
Your pet typically... loves to eat / is not food motivated / is picky?
Vomiting- none / occasional / a couple of times per week / often? (If vomiting is a regular occurrence, please describe when it happens and what it looks like.)
Stools – normal / soft/ diarrhea / hard and dry /constipation / incontinent?
Is there is blood / mucous in the stool?
Odor of stool – normal / strong / no odor?
Does your pet have gas? Yes / No
Thirst – normal/increased/decreased
Water intake - Frequent small sips/large amounts at one time/ moderate
Urine – normal/increased/decreased / Incontinent / Straining/ Vocalizes
Color of urine? Normal/clear/dark yellow
Odor of urine? Normal/no odor/strong odor
My pet has: Brittle nails /dry pads /dry skin with large flakes / dry skin with small flakes
Is your pet itchy? No / Yes
If “Yes” please indicate all that apply: sometimes / during day / at night / all the time
Has your pet’s hair coat changed? No / Yes, describe:
Describe any reproduction problems your pet has had:
My pet is normal / coughs / has had a change in breathing, describe:
My pet’s voice or noises that he/she makes are: the same / have changed, describe:
Which of the 5 Elements (image to the right) sounds most like your pet?
Is there anything else we should know about your pet’s health or emotional history?