Acupuncture Initial Questionnaire

Thank you for choosing Hatton Veterinary Hospital.

Acupuncture Initial Questionnaire

Before your appointment, please complete this form as thoroughly and correctly as you can so that we may get to know you and your pet(s).

Date

Patient's Name

Caretaker's Name *

First

Last

Age or DOB:

Sex

What are the main concerns (in order of priority)?

When do these problem(s) occur during the day/night, and how often?

How long have the issues been occurring and when did they first start?

Have there been any changes in routine, household member, schedule, etc. recently, and if so, what are they?

Does anything cause the condition(s) to worsen?

What does your pet eat (include type, quantity, timing, snacks, home cooked foods)? Does your pet have a good appetite?

What medications or supplements is your pet on currently (include names, dosages and how often they are given)?

Does your pet prefer seek warm or cool environments generally?

Has your pet ever had seizures, exposure to toxins, emotional or physical trauma?

Are there any behavior changes that you have noticed recently? Anxiety? Describe.

Is your pet vomiting? If so, how often, when does it occur, what does it look like?

Is your pet having diarrhea? If so, how often, when, what does it look like?

Is your pet coughing or sneezing? Do they breathe fast/slow/normally? Loudly/softly? Has their bark/meow changed? Is it loud/soft?

Is your pet’s coat dry/moist/normal? Do the nails or pads seem dry or normal? Are they itchy?

Does your pet drink a lot/ a little/ normal amount of water? How often do they urinate/day? Is it normal/strong/dilute?

Is your pet having any trouble sleeping? How so?

Is your pet stiff or limping? If so how long has this been going on? When is it most noticeable?

Is your pet in pain? Please describe.

Does your pet stay indoor/outdoor primarily? Does your pet travel?

How would you describe your pet’s personality (is he/she outgoing and cheerful, easily frightened, friendly to strangers, aggressive towards strangers, likes new things, frightened of everything, likes to be in charge, likes to follow others, is generally aloof, follows rules, breaks rules, laid back, has more energy than they can deal with, etc.)?

Please list other pets that live with your pet (including age, breed, how long they have been together):

Other information or concerns you wish to share:

Acupuncture Initial Questionnaire

Acupuncture Initial Questionnaire

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