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Animal Acupuncture Ottawa
Patient History Form
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Client Name
*
Address
*
City
*
Province
*
Postal Code
*
Email Address
*
Phone Number
*
Your pet’s information
Pet’s Name
*
please any what
What species is your pet?
*
What breed is you pet?
Is your pet:
Male
Male neutered
Female
Female spayed
What is your pet’s birth date or estimated age?
Does your pet prefer warm or cool places, or neither?
Warm
Cool
Neither
If neither, please describe:
Has your pet shown any behavioural, personality, or temperament changes recently?
Yes
No
Unsure
If yes, please describe:
What kinds of commercial food, human food, and treats does your pet regularly eat?
What kinds of commercial food, human food, and treats does your pet regularly eat? (copy)
Please list all medications or supplements that your pet is currently receiving
Your pet’s behaviour – questions 1-5
1 - Which of the following words best describe your pet when healthy and feeling well?
Dominant
Assertive
Competitive
Confident
Fearless
Adaptive
Intolerant
Decisive
Impulsive
Athletic
Strong
Other
Other (please describe)
2 - Which of the following words best describe your pet when healthy and feeling well?
Easily excited
Extroverted
Enthusiastic
Playful
Sensitive
Difficult to calm down
Noisy/Vocal/Communicates
Enjoys attention
Enjoys physical contact
Lively
Affectionate
Other
Other (please describe)
3 - Which of the following words best describe your pet when healthy and feeling well?
Laid back
Good appetite
Friendly
Balanced
Slow moving
Easily satisfied
Kind
Tolerant
Relaxed
Loyal
Consistent
Other
Other (please describe)
4 - Which of the following words best describe your pet when healthy and feeling well?
Aloof
Independent
Ordered
Routine
Quiet
Confident
Consistent
Good fur coat
Follows commands
Likes structure
Self driven
Other
Other (please describe)
5 - Which of the following words best describe your pet when healthy and feeling well?
Timid
Introverted
Shy
Solitary
Hesitant
Fearful
Observant
Careful
Hides
Thoughtful
Runs away
Other
Other (please describe)
Your pet’s symptoms
Questions 1-7: If you reply yes to any of the following, please describe.
1 - Has your pet had any vomiting?
Yes
No
Yes, please describe
2 - Has your pet had any diarrhea?
Yes
No
Yes, please describe
3 - Has your pet had any change in drinking or urination quantities?
Yes
No
Yes, please describe
4 - Has your pet had any excessive itching or scratching?
Yes
No
Yes, please describe
5 - Has your pet had any coughing or sneezing?
Yes
No
Yes, please describe
6 - Has your pet experienced any lameness?
Yes
No
Yes, please describe
7 - Does your pet have any lumps or bumps?
Yes
No
Yes, please describe
How well does your pet sleep through the night?
Normal
Difficulty falling asleep/restless, takes a long time to settle
Frequently waking up in the night
How is your pet’s appetite?
How are your pet’s energy levels?
What are the main health problems that your pet is experiencing?
*
Do any of these problems happen regularly at the same time of day?
Yes
No
If yes, what time of day?
How long have these problems been present?
Which conditions or activities cause these problems to worsen?
What treatments have been tried previously for your pet’s current health concern?
Has your pet previously had acupuncture?
Yes
No
If yes, for what problem and what was the outcome of treatment?
Have any diagnostic tests been performed related to your pet’s current health concern?
Yes
No
If yes, what diagnostic tests have been performed, and at which clinic(s)?
Is there another veterinary clinic that we can contact to obtain a copy of your pet’s medical records?
What are your goals for your pet’s treatment with Acupuncture and Traditional Chinese Veterinary Medicine?
*
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Patient History Form
Contact Us
Name
Email
Message
Send
Email:
anima
lacupuncture
of
ottawa@gmail.com
Phone:
613
-
592-
324-
1230
