Your Info Full Name Phone Email Address Your Pet's Info Name Species Dog or Cat? Dog Cat Sex Please Choose Spayed Female Intact Female Neutered Male Intact Male Breed Weight Date of Birth More Info Reason(s) for acupuncture visit: What do you feed your pet? (brand, flavor, amount and frequency). Any treats? Any previous health issues? Please list all medications and supplements your pet takes (including heartworm and flea preventative). Is your pet up to date on vaccines? Please Choose Yes No I don't know Assess Your Pet Normal Increased Decreased Activity Level Normal Increased Decreased Sleep Normal Increased Decreased Food Intake Normal Increased Decreased Water Intake Normal Increased Decreased Urination Normal Increased Decreased Stiffness Normal Increased Decreased Voice Normal Increased Decreased Panting Normal Increased Decreased Check all that apply: Coughing Belching Or Gas Vomiting Sneezing Abnormal Stool None Of These Assessment Comments: And Finally Which of these best describes your pet? (They may have characteristics of more than one) Wood - Dominant, aggressive, competitive, athletic, confident, fearless, can be irritable or anger easily Fire - Friendly, playful, sensitive, noisy/talkative, wants to be petted, center of attention, strong body, can be hyperactive or have anxiety Earth - laid back, easy going, friendly, slow moving, sweet, tolerant, nuturing, worries, can overeat/prone to obesity Metal - aloof, independent, likes order and rules, quiet, upset with change, can become sad/depressed Water - timid, shy, fearful, nervous, fear-biter, likes to hide, careful and curious ** if you were referred by a current client, please provide the name so that we can proprly thank them =) Additional Comments: Give Consent I have read and agree to the Consent To Proceed With Acupucture Owner
