Shuler VC - Acupuncture Questionnaire

1
* This field is required.
Client Name
Pet Name
Phone
Email
2
Has your pet ever had acupuncture?* This field is required.
YESNO
3
If so, date of last session and outcome.* This field is required.
4
Primary concern(s):* This field is required.What is your pet's primary concern/problem areas?
5
How long has this been a concern?* This field is required.
6
List all medications and supplements your pet is on* This field is required.If not applicable please put None.
7
List all foods/treats your pet eats* This field is required.
8
Describe your pet’s appetite, time of day he/she eats.* This field is required.
9
Is your pet a picky eater?* This field is required.
10
Have you noticed increased thirst?* This field is required.
YESNO
11
What are your pets drinking habits?* This field is required.
drinks a lot at once
drinks small amounts many times throughout the day
12
Temperature preference:* This field is required.
Shade or cool locations (tile, in front of AC vents)
Sun or warm locations (carpet, bedding)
13
Sleeping habits:* This field is required.
sleeps through the night
gets up and moves around through the night
has a hard time falling asleep
dreams frequently
Other
14
Other sleeping habits to note:* This field is required.
15
Stool Quality:* This field is required.
normal
dry/hard
bloody
malodorous
soft/loose
diarrhea
16
Urination Quality: * This field is required.
normal
short, frequent streams
bloody/malodorous
urinary leakage
long streams
increased frequency
17
Is your pet sneezing or coughing?* This field is required.
YESNO
18
If coughing or sneezing, please describe:* This field is required.
19
Has there been any vomiting?* This field is required.
YESNO
20
If vomiting, please describe:* This field is required.
21
Have there been any changes to your pet’s energy and/or stamina?* This field is required.
YESNO
22
If yes, please describe:* This field is required.
23
What is your pet’s personality? * This field is required.
bossy/aggressive
very friendly - runs up to play with other dogs/people
happy to play, but lets them come to him/her
doesn’t really care/aloof
timid/scared/runs away
24
* This field is required.
Is your pet patient?
Is your pet easily excited/startled? (Doorbell, loud noises)
Does your pet seem to like rules or “need a job”?
25
Has your pet had any major illnesses, injuries, or surgeries in his/her lifetime?
26
Is there anything else I should know about your pet?
Should be Empty: