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AcupunctureQuestionnaire

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Acupuncture Questionnaire

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Welcome to the world of Integrative Veterinary Medicine, the combination of Conventional (or Western) Modern Medicine and Traditional Chinese Medicine. You are about to fill out a medical history that far surpasses your past experiences. Some of these questions may be straight forward, and some may be a little “weird”, to say the least. In Traditional Chinese Veterinary Medicine, clues to the body’s health are everywhere; we just have to ask the correct questions.

Please take the time to fill out this very LONG questionnaire to the best of your ability. It may be best to read the questionnaire, fill out the easier points and then observe your pet for the next couple of days to answer the more “obscure” questions. The more detailed and accurate your answer, the more accurate the Traditional Chinese Medical diagnosis will be, and therefore the more effective the treatment can be.

Name(Required)

First Last

Patient Name(Required)

Primary Care Veterinary Clinic(Required)

What are the main reasons you are seeking an Integrative consultation and acupuncture treatment? If there is more than one health concern at this time, please list them in order of DECREASING importance to you.(Required)

What are your expectations / goals with acupuncture treatments?(Required)

Were your referred by someone for acupuncture?(Required)

Yes

If so, by whom?(Required)

Have you ever had an acupuncture treatment yourself?(Required)

Yes

INHERENT CONSTITUTIONS

In Traditional Chinese Medicine, individuals can be categorized to fit into one or two particular Elements. The state of an individual’s health can be influenced by their “inherent” elemental status. An individual’s inherent constitution influences the animal’s body structure, health, emotions, and when exposed to the same stress factors, individuals of different constitutions will react in a different way, whether it is positively or negatively. When a constitution is in balance, there is harmony and health in the system. When unbalanced, there is disease. Check all that apply below for your pet so we can get a better idea of their inherent constitution.

FIRE(Required)

EARTH(Required)

WOOD(Required)

METAL(Required)

WATER(Required)

REST AND ACTIVITY LEVEL

CHECK ALL THAT APPLY(Required)

How long does it take for your pet to get up?(Required)

Less than 5 seconds

5 to 30 seconds

30 seconds to 60 seconds

Greater than 60 seconds

CHECK ALL THAT APPLY(Required)

POSTURE, GAIT AND MOVEMENT

CHECK ALL THAT APPLY(Required)

If patient has an obvious limp, please specify below:(Required)

Front right leg

Front left leg

Rear right leg

Rear left leg

If had recent x-rays of spine or legs, then when?(Required)

EXERCISE

CHECK ALL THAT APPLY(Required)

My pet walks every day

My pet walks multiple times a day

My pet walks at least two to three times a week

My pet walks occasionally, once every week to two weeks

My pet’s exercise is limited to the yard

My pet cannot exercise because of his/her health issues

My pet goes to the dog park.(Required)

Yes

If yes, how often?

My pet goes to doggy daycare.(Required)

Yes

If yes, how often

My pet does not go for walks but exercises by:

URINATION

Please take the time to observe your pet’s behavior regarding elimination for the next few days in order to answer the following questions.

CHECK ALL THAT APPLY(Required)

DEFECATION

CHECK ALL THAT APPLY(Required)

Pet intermittently has loose stools.(Required)

Yes

If so, how often is your pet having this issue?(Required)

Daily

Weekly

Every two weeks

Monthly

Every 2-3 months

What time of day do the abnormal bowel movements occur?(Required)

Unknown

After eating

Mornings

Evenings

Anytime

Pet had a recent fecal parasite screening.(Required)

Yes

If so, when?

Pet is current with a monthly deworming medication.(Required)

Yes

If so, what brand?(Required)

VOMITING

Check all that apply(Required)

Pet is not vomiting

Pet chronically vomits

Pet intermittently vomits

Pet rarely vomits

How often is your pet vomiting?(Required)

Daily

Weekly

Every 2-3 weeks

Monthly

Every few months

What time of day is your pet vomiting?(Required)

Unknown

After eating

Mornings

Evenings

Anytime

What are the contents of the vomit?(Required)

Undigested food

Hair

White/Clear fluid

Yellow bile

Blood tinged fluid

RESPIRATION

Check all that apply(Required)

Pet is not having breathing issues

Pet has a hard time breathing after exercise

Pet has a hard time breathing at rest

Pet pants when temperature is hot

Pet pants off and on during the day (at rest)

Pet breaths loudly upon inhalation

Pet breaths loudly upon exhalation

Pet had a low-pitched wheeze

Pet has a high-pitched wheeze

Pet coughs frequently(Required)

Yes

If so, when?(Required)

Mostly in the morning

Off and on all day

Mostly in the evening

Mostly at night

After exercise

After eating/drinking

Check all that apply(Required)

Pet coughs then gags

Pet gags then coughs

Cough is dry (non-productive)

Cough is wet (productive)

Cough is forceful/strong/loud

Cough is weak

Pet has had recent thoracic x-rays.

Yes

If so, when?

Pet has had a recent heartworm test.

Yes

If so, when?

Pet is current on monthly heartworm medication.

Yes

If so, what brand?

ENVIRONMENT AND LIVING SITUATION

Check all that apply(Required)

If pet was rescued/rehomed as an adult. At what age?(Required)

If shares home with other pets, list number of dogs/cats:(Required)

Describe the problems with other pets:(Required)

There have been no changes to the number of pets in the household in the past year(Required)

Yes

Pets were added to the household within the past:

Less then month

1-3 months

3-6 months

6-12 months

There were no issues with the new pets

There have been issues with the addition of new pets

Pets have been lost to the household within the past:

Less then month

1-3 months

3-6 months

6-12 months

My pet was not affected by the loss

My pet was affected by the loss

Describe your pet’s changed behavior if applicable to the addition or loss of other pets:

Recently and overall, my pet’s attitude toward life, family and surroundings has been:(Required)

Normal

Slightly less than normal

Abnormal, subdued

Abnormal, hyperactive

Attitude is progressively getting worse

Attitude, though abnormal, has improved recently

SKIN AND HAIR COAT

Check all that apply(Required)

Pet has not had recent skin / hair issues

Pet historically has had skin / hair issues

Pet is currently having skin / hair issues

Pet seasonally has skin / hair issues

Check all that apply(Required)

Pet is scratching?(Required)

Yes

If so, how bad on a scale of 1-10?(Required)

Where is your pet scratching? Check all that apply:(Required)

Head/Face

Ears

Neck/Chin

Under arms/legs

Flanks

Tail

Pet goes to the groomer?

Yes

If so, how often?

Pet is on current on flea/tick prevention?

Yes

If so, what brand and when was it last given?

MENTAL STATUS AND VOCALZIATION

For those of you who work between 8 AM and 6 PM, it is difficult to answer some of the questions with specific times. Rely on your observations during your days off and on weekends. Unless there is a lot going on in the household, most pets will stick to their same schedules of behavior, even on the weekend.

Check all that apply(Required)

Comments:

DIET

Check all that apply(Required)

List trigger foods:(Required)

What happens when the trigger food is fed:(Required)

Dry food:

List brand & flavor of food and frequency fed (Ad lib, 1x/day, 2x/day,3x/day)

Wet food:

List brand & flavor of food and frequency fed (Ad lib, 1x/day, 2x/day,3x/day)

Raw food:

List brand & flavor of food and frequency fed (Ad lib, 1x/day, 2x/day,3x/day)

Treats:

List brand & flavor of food and frequency fed (Ad lib, 1x/day, 2x/day,3x/day)

Meat / Protein:

List brand & flavor of food and frequency fed (Ad lib, 1x/day, 2x/day,3x/day)

Vegetable / Fruit:

List brand & flavor of food and frequency fed (Ad lib, 1x/day, 2x/day,3x/day)

Is there anything else that you feed that is not covered above?

If you feed only human food, do you supplement with vitamins or minerals?

Yes

If so, please list the brand:

If you feed a raw diet of your own making, do you follow guidelines?

Yes

If so, please list the source:

APPETITE AND DRINKING BEHAVIOR

Check all that apply(Required)

Comments:

CURRENT MEDICATIONS AND SUPPLEMENTS:

Patient is currently on medication?(Required)

Yes

List Drug/Supplement Name, Dosage (mg), Frequency (How often given):(Required)

Patient is taking supplements?(Required)

Yes

List Drug/Supplement Name, Dosage (mg), Frequency (How often given):(Required)

TEMPERATURE / ENERGETICS:

YIN (EXCESS COLD)(Required)

YANG (EXCESS HEAT)(Required)

Do you have any other comments about your pet’s medical history that were not addressed above?

Name

This field is for validation purposes and should be left unchanged.

Form

AcupunctureQuestionnaire

Acupuncture Questionnaire

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

INHERENT CONSTITUTIONS

REST AND ACTIVITY LEVEL

POSTURE, GAIT AND MOVEMENT

EXERCISE

URINATION

DEFECATION

VOMITING

RESPIRATION

ENVIRONMENT AND LIVING SITUATION

SKIN AND HAIR COAT

MENTAL STATUS AND VOCALZIATION

DIET

APPETITE AND DRINKING BEHAVIOR

CURRENT MEDICATIONS AND SUPPLEMENTS:

TEMPERATURE / ENERGETICS:

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