Acupuncture Form

Welcome to the world of Integrative Veterinary Medicine, the combination of Conventional (or Western) Modern Medicine and Traditional Chinese Medicine. Please take the time to fill out this 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 questions you are not sure about. The more detailed and accurate your answers, the more accurate the Traditional Chinese Medical diagnosis will be, and therefore the more effective the treatment can be. Treatment success is based on identifying an individual patient's underlying “pattern” of imbalance and how it may be contributing to health problems unique to them. These questions, along with a Traditional Chinese Medicine Veterinary Exam, will guide how we approach needle placement, and what supplemental food therapies or Herbal therapies we can consider adding to help re-balance the body.

Medical History

Name(Required)

First Last

Patient Name(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 the most important first.

What are your expectations/goals with acupuncture treatments?

Inherent Constitutions

In Traditional Chinese Medicine, individuals can be categorized to fit into one or two particular Elements. There are five elements, and it organizes certain characteristics of an individual's personality to describe the relationship between the body's internal organs as well as the relationship between the body and the natural environment in which it exists. The state of an individual's health can be influenced by their "inherent" elemental status and 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. Do not worry if you have several symptoms or characteristics that fall into different boxes!

Balanced (Fire)

Imbalanced (Fire)

Earth

Balanced (Earth)

Imbalanced (Earth)

Metal

Balanced (Metal)

Imbalanced (Metal)

Wood

Balanced (Wood)

Imbalanced (Wood)

Water

Balanced (Water)

Imbalanced (Water)

Temperature / Energetics

Is your pet mostly(Required)

Heat seeking (Likes to be under blankets, in the sun for long periods, has an aversion to going outside when it is cold)

Cold seeking (Likes to be on cool floors, seeks shade. sleeps on top of blankets, pants often and drinks water frequently)

Neutral

Check all that apply

YIN (Excess Cold)

YANG (Excess Heat)

General Behavior

Does your pet sleep through the night?(Required)

Yes

You selected "No", please describe what happens(Required)

What is your pet’s current energy level? How does this compare to their usual?

Appetite and Drinking Behavior

Appetite(Required)

Normal

Decreased

Increased

Eating Habits(Required)

Changed

Unchanged

Water Intake(Required)

Normal

Decreased

Increased

Vomiting and Defecation

Vomiting?(Required)

Yes

How often is your pet vomiting?(Required)

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

What are the contents of the vomit?(Required)

Undigested food

Hair

White / clear fluid

Yellow bile

Blood tinged fluid

Other

Have you noticed any of the following signs of acid reflux?

Dry gagging or hacking cough

Repeated swallowing

Lip licking

Burping

Foul breath (like rancid food)

Licking surfaces (floors, walls, carpet)

Are your pet's stools:(Required)

Normal

Abnormal

Describe what they look like?(Required)

How often is your pet having abnormal stool?(Required)

Daily

Weekly

Monthly

Every 2-3 months

Does your pet experience any of the following?

Intestines that gurgle

Flatulent / passing gas

Fecal incontinence

Constipation

Urination and Drinking

Is your pet's urination:(Required)

Normal

Increased amount

Decreased amount

Bloody

Incontinent (dribbling or leaving puddles when resting)

Is your pet's water intake:(Required)

Normal

Increased

Decreased

Coughing and Sneezing

Is your pet coughing?(Required)

Yes

Is your pet sneezing?(Required)

Yes

Skin and Hair Coat

What, if any, skin and hair coat issues is your pet experiencing?

Rate your pet’s level of scratching on a scale from 0 (no scratching at all) to 10 (pet is unable to stop scratching for any reason)(Required)

Please enter a number from 0 to 10.

Mental Status

Has your pet undergone or experienced any recent stress? Check any that apply

Loss of a housemate (human or animal sibling)

Recent adoption / addition of new pets to the household

Recent move

Recent stress at boarding or at home while you were traveling

Pain

Do you perceive your pet is in pain?(Required)

Yes

Where do you think the pain is located?(Required)

Rate their pain on a scale of 0 (no pain) to 5 (extreme pain)(Required)

Please enter a number from 0 to 5.

Diet

Please detail your pet's current diet(Required)

Current Medications and Supplements

Please detail your pet's medications and supplements(Required)

Further Comments

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

Authorization to Perform Alternative Therapy and Release of Liability

Owner’s Full Name - (Filling out this field constitutes your signature)(Required)

Today's Date(Required)

Acupuncture Form

Medical History

Inherent Constitutions

Earth

Metal

Wood

Water

Temperature / Energetics

General Behavior

Appetite and Drinking Behavior

Vomiting and Defecation

Urination and Drinking

Coughing and Sneezing

Skin and Hair Coat

Mental Status

Pain

Diet

Current Medications and Supplements

Further Comments

Authorization to Perform Alternative Therapy and Release of Liability

Expert Veterinary Care in Fort Collins, CO