Acupuncture & Integrative Medicine History Form – Hampton Roads Veterinary Hospice

Owner's Name *

First

Last

Date

Address

Address Line 1

City

State

Zip Code

Phone *

Email *

Pet's Name *

Species *

Dog
Cat
Other

If Other, please specify

Breed

Color

Age

Weight

Sex *

Male
Female
Neutered Male
Spayed Female

What is your pet's main reason for seeking acupuncture? *

General Wellness
Health Problems (describe below)

If health problem(s), please describe below

What diagnostics have been performed and what were the results? (x-rays, bloodwork, etc..)

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:

the same
better
worse

Current Medications: *

Current Herbs and/or Supplements: *

Current Diet:

Current Exercise Regimen:

Energy Level (overall)

Normal
Increased
Reduced

Energy is highest in the:

Morning
Afternoon
Evening
Consistent throughout the day

Attitude/Mood is best in the:

Morning
Afternoon
Evening
Consistent throughout the day

My pet is: (check all that apply)

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 in the:

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?

Yes
No
Maybe

Pain is a ___ on a scale of 1-10.

Is the pain in a specific area? If yes, where?

Is the pain better or worse after rest?

Better
Worse
No change

Is the pain better or worse after exercise?

Better
Worse
No change

How does the weather/temperature affect your pet's pain?

Your pet typically...

loves to eat
is not food motivated
is picky

Vomiting:

If other, please specify:

Stools:

If other, please specify:

Is there a strong odor to stools?

yes
no
maybe
other

If other, please specify:

Does your pet have gas?

yes
no
maybe
other

If other, please specify:

Thirst:

Normal
Increased
Decreased

Water intake:

Frequent small sips
Large amounts at one time
Moderate

Urine

Urine Color:

Normal
Clear
Dark Yellow
Blood

My pet has:

brittle nails
dry pads
dry skin with large flakes
dry skin with small flakes

Is your pet itchy?

Yes
No

If yes, please indicate all that apply:

sometimes
during the day
at night
all the time

Has your pet's hair coat changed?

Yes
No
Other

If other, please specify:

Describe any reproduction problems your pet has had:

My pet is:

normal
coughs
has had a change in breathing (describe below)
other

Describe your pet's change in breathing:

If other, please specify:

My pet's voice or noises that he/she makes are:

normal
have changed (describe below)
other

Describe your pet's change in noise/voice:

If other, please specify:

If your pet could have any human job or career, what would it be?

Please look at this image and answer the question below: https://hrvethospice.com/wp-content/uploads/2019/06/5-element-theory.png

Which of the 5 Elements (see image above) sounds most like your pet?

Is there anything else we should know about your pet's health or emotional history?