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Acupuncture Questionnaire

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Acupuncture Questionnaire

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Client Information
Please read through and fill out entire form and submit along with your pet's medical records (if you have not yet provided them and are coming to us from another clinic).

First Name: *

Last Name: *

Email: *

Phone: *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Referring Veterinarian (if outside clinic): *

Pet Information

Pet's Name: *

Breed: *

Color: *

Species: *DogCat

Sex: *MaleNeutered MaleFemaleSpayed Female

Age: *

Medical Information

Medications: List all, including flea and heartworm prevention. *

Herbal/Supplements: List all prescribed and over the counter supplements. *

Diet: What brand? How much? How often? Also include treats and home cooked ingredients if they apply. *

What are your primary concerns today? Why did you schedule an acupuncture consultation? *

What is your expected outcome with acupuncture treatment? *

Water Intake: *NormalDrinks Very LittleIncreasedDecreased

Food Intake: *NormalFinickyPoor AppetiteRavenous

Voice: *NormalLoudWeak

Vomiting Amount: *MuchLittleJust After Eating

Urine: Check any/all that apply: *LongShortIncontinentStrong Odor

Feces: Check any/all that apply: *SoftWateryDryConstipatedBloodyMucousIncontinentStrong Odor

Cough: Check any/all that apply. *DryWetLoudWeakDaytimeNighttimeWorse at Night

Sleeping: Check any/all that apply *All the TimeVery LittleVocalizes/Wakes Owner at NightLikes a Soft BedLikes Hard SurfacesPrefers to Lie in the SunPrefers to Lie in the Shade

Breathing: Check any/all that apply. *NormalStrongShallowFast

Stiffness: *NoneChronicRecent Onset

Activity Level: *NormalIncreasedDecreased

Temperature Preference: *No Temperature PreferenceLikes Warm SurfacesLikes Cool Surfaces

Please Check All That Apply to Your Pet

AssertiveConfidentStrongImpulsiveAthletic / StrongAlphaLigament ProblemsLiver ProblemsRed EyesEar ProblemsNail ProblemsFootpad ProblemsAnal Sac IssuesLivelyCommunicativeVery FriendlyAffectionateLoves to be PettedCenter of the PartyInsomniaSeparation AnxietyRestlessnessRapid Heart RateHeart ProblemsAngers EasilyRelaxed, Laid-BackSociableRound/LargeLoyalSerene and BalancedMotherly InstinctCarefulCuriousSelf-containedLikes to HideMeditativeSlow and ConsistentLoves OrderObeys the RulesAloofAsymmetrical BodyDisciplined AttitudeGood HaircoatAsthmaDry SkinSinus ProblemsBreathing DisorderNose ProblemsCoughDiarrheaConstipationLoss of AppetiteVomitsGum DiseaseWeak MusclesOvereatsObeseWorriesRear WeaknessFearfulBone/Back IssuesUrinary ProblemsDisturbed GrowthDeafnessReproductive Problems

Please do not fill in this field.

Luv-N-Care Animal Hospital

1482 N Ronald Reagan Blvd
Longwood, FL 32750
t: 407-767-0606

Also serving Orlando, FL and surrounding areas.

Working Hours

Monday: 7:30am – 7:00pm
Tues-Thurs: 7:30am – 6:00pm
Friday: 7:30am – 7:00pm
Saturday: 8:00am – 3:00pm
Sunday: 9:00am – 4:00pm

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Luv-N-Care Animal Hospital

Our Location

1482 N Ronald Reagan Blvd
Longwood, FL 32750
407-767-0606

Also serving Orlando, FL
and surrounding areas.

Our Hours

Monday: 7:30am – 7:00pm
Tues-Thurs: 7:30am – 6:00pm
Friday: 7:30am – 7:00pm
Saturday: 8:00am – 3:00pm
Sunday: 9:00am – 4:00pm

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