ACUPUNCTURE INTAKE QUESTIONNAIRE CLIENT INFORMATION * First Name Last Name Date MM DD YYYY Patient's Name * Patient’s D.O.B or Approximate Age * Breed * Color/Markings * Chief Complaint * Previous Medical History * Current Medications and supplements, including dosage * Any history of food or drug sensitivity? Yes No If so, how? Appetite: (i.e. Normal, finicky, ravenous, etc.) * Thirst: (i.e. Normal, increased, temperature preference) Hot vs Cold: (i.e. Seeks sun / cool tile floor, sleeps under / above covers, etc.) * Sleep: (i.e. Energy in AM, dreaming, restlessness, snoring, etc.) Personality: (i.e. Friendly, timid, fear aggressive, changeable temperament, noise sensitivity, etc.) DIGESTIVE SYSTEM Diarrhea: Yes No If yes, please describe (i.e. Mucus, blood, undigested food, color, odor, time of day) Vomiting: Yes No If yes, please describe (i.e. Color, odor, undigested food, time of day): Tenesmus / Constipation: Yes No Halitosis / Bloating / Gas: Yes No Please specify and explain: URINARY SYSTEM Bladder Infections: Yes No Please describe (Strangurea, blood, treatment): Incontinence: Yes No Please describe (Time of day, worse after exercise): Polyurea (production of abnormally large volumes of dilute urine): Yes No Please describe (color, odor) RESPIRATORY SYSTEM Coughing: Yes No Sneezing Yes No Stamina / Shortness of breath: Yes No Please describe (effect of weather or exercise): DERMATOLOGY Puritis (severe itching of the skin): Yes No Please describe (mild / severe, seasonality): Discharge: Yes No Please describe (i.e. Mild dandruff vs large flakes, effect of oil, moist/dry): Otitis Externa (inflammation or infection of the external auditory canal): (i.e. odor, moist/dry, effect of season, puritis): Ability to regrow hair: Past Medications: (treatments / outcomes) MUSCULOSKELETAL SYSTEM Stiffness / soreness: Yes No Please describe (Better with rest or movement, heat / cold, touch): Lameness: Yes No Please describe (Better with rest or movement, heat / cold, touch): Chronic pain / trauma: Yes No Please describe (Better with rest or movement, heat / cold, touch): HEAD Eye discharge: Yes No Please describe (Color, mucus, moist vs dry, seasonality, medications): KCS: – dry eye syndrome Yes No Loss of vision or sight: Yes No Thank you!
