SouthParkAustin - Acupuncture Patient History Questionnaire

1
Email address * This field is required.
example@example.com
2
Phone Number
Area Code
Phone Number
3
What is your preferred method of communication?* This field is required.
Phone Call
Text Message
4
Pet's Name
Please Select
Please Select
Dog
Cat
Species
Breed
5
Date of Birth
Date
Year
Month
Day
6
Please Select
Please Select
Female
Male
Sex
At what age was your pet spayed/neutered?
7
How would you describe your pet’s personality? Some pets may exhibit multiple personality traits, so just choose the grouping that fits best.* This field is required.
Confident, competitive, athletic, fearless, dominant
Friendly, excitable, sensitive, noisy, loves attention and being petted
Mellow, sweet, tolerant, friendly, slow moving
Aloof, independent, quiet, likes order and rules
Timid, fearful, solitary, introverted, observant
8
What type of food do you currently feed? Include brand, type (dry, canned, cooked, raw) and amount fed.* This field is required.
9
What are your pet’s current medications? Include preventatives, nutraceutical products/ supplements, and holistic medications such as herbs.* This field is required.
10
What type of exercise does your pet receive? *
Has your pet exhibited any behavior changes recently? *
Does your pet prefer warm or cool places? *
11
Have you noticed any changes to GI health--change in appetite (increased or decreased), soft stool, constipation, or vomiting?* This field is required.
12
Have you noticed any changes in drinking or urination? * This field is required.
13
What are the main health concerns that your pet is experiencing, and for how long have they been present?* This field is required.
14
For chronic diseases, have you noticed any conditions that cause the problems to worsen (warm or cool temperature, worse after exercise or rest, worse during the morning, afternoon, or night)?* This field is required.
15
Has your pet ever had acupuncture or herbal medications, and for which conditions?* This field is required.
16
Are there any parts of your pet’s body that have previously been sensitive to handling?* This field is required.
Should be Empty: