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Acupuncture New Patient Form
1. Please enter your information.
First Name
*
Middle Initials
*
Last Name
*
Street Address
*
City
*
State
*
Zip Code
*
Mobile Phone
*
Home Phone
*
Work Phone
*
Email
*
Preferred contact method:
*
Preferred contact method:
A
Mobile Phone
B
Home Phone
C
Work Phone
D
Email
2. Please alternative contact information.
First Name
*
Middle Initials
*
Last Name
*
Street Address
*
City
*
State
*
Zip Code
*
Mobile Phone
*
Home Phone
*
Work Phone
*
Email
*
Preferred contact method:
*
Preferred contact method:
A
Mobile Phone
B
Home Phone
C
Work Phone
D
Email
3. Pets information
Pet's Name
*
Current age of pet?
*
How old was your pet
when you obtained
him/her?
*
Pet breed?
*
Pet Color
*
Sex
*
Sex
A
Male
B
Female
C
Male- Neutered
D
Female- Spayed
If your pet is spayed/neutered, how old was your pet
at the time of the surgery?
4. Diet: What does your pet eat?
Current food fed to your pet: Please list brand
*
What is the protein source? (Beef, chicken, etc)
*
Is the food a kibble, canned, or raw? Please describe
*
Please list what type of treats you give your pet and
how often you give them
*
Would you like information on
preparing a home cooked diet?
*
Would you like information on preparing a home cooked diet?
A
Yes
B
No
C
Maybe
5. Medical
Is your pet on any current
medications/supplements/vitamins?
*
Is your pet on any current medications/supplements/vitamins?
A
Yes
B
No
Please list:
Does your pet have any food
allergies or sensitivities?
*
Does your pet have any food allergies or sensitivities?
A
Yes
B
No
If yes, please list:
Has your pet had any adverse reactions to
medications? If yes, please list
*
Does your pet have any other allergies? If yes,
please list:
*
Are the allergies seasonal?
Do you feel like your pet has a sensitive stomach? If
yes, please describe:
*
Has your pet had any major illnesses, diseases, or
injuries?
*
Has your pet been diagnosed with any disorders of
the immune system?
*
Has your pet had any prior surgeries? If yes, please
list type and year:
*
Does your pet have a history of seizures? If so,
please describe:
*
Is your pet experiencing any problems in sight?
*
Is your pet experiencing any problems in hearing?
*
Have you noticed any changes in your pet's
bark/meow?
*
Does your pet have any trouble getting up from lying
down?
*
Does your pet have trouble lying down?
*
Does your pet have trouble going up stairs?
*
Does your pet have trouble going down stairs?
*
What type of flooring is in your home?
*
Do you feel your pet is in pain?
*
Do you feel your pet is in pain?
A
Yes
B
No
If so, please rate the pain
on a scale of 1-, where 1
is very little and 10 is the
worst:
Do you feel your pet is stiff?
*
Do you feel your pet is stiff?
A
Yes
B
No
Do you feel your pet is weak?
*
Do you feel your pet is weak?
A
Yes
B
No
Are the above signs (pain, stiffness, or weakness)
worse in the following:
*
Are the above signs (pain, stiffness, or weakness) worse in the following:
A
Heat
B
Cold
C
Wet
D
No difference
Please describe your pet's current activity level:
*
Do you take your pet on regular walks?
*
Do you take your pet on regular walks?
A
Yes
B
No
C
Other
If yes, how long/far and how often?
Does your pet sleep well? If not,
please elaborate:
*
How does your pet do with other
animals?
*
How does your pet do with
people?
*
Is our pet exhibiting any signs of stress or other
behavior problems?
*
Do you feel your pet is anxious? If yes, in what
circumstances does your pet become anxious?
*
Does your pet prefer warm or cool
places?
*
Does your pet prefer warm or cool places?
A
Warm
B
Cool
C
No preference
Please describe your pet's personality in 2-3 words:
*
What is your primary concern for your pet today?
*
When did the problem first start?
*
Has the problem gotten better or worse since it
started?
*
Has the problem gotten better or worse since it started?
A
Better
B
Worse
C
No change
D
Other
Is the problem worse at certain times of the day?
*
Is the problem affected by weather?
*
Is the problem affected by exercise?
*
What are the primary goals for your pet?
*
Is there anything else you would like to discuss with
the doctor?
*
Submit
