Integrative Medicine Form

Details are important to us – so we start our journey together with a detailed new patient form and review of prior medical records.

Integrative Medicine Form
What is your name?
What is your name?
First
Last
What gender is your pet?

Maximum file size: 104.86MB

Please include any treats you give.
What does your pet's personality most closely resemble?
What is your pets main reason for seeking accupunture
Since your pet's last veterinary visit, is he/she:
What is your pet's general energy level?
My pet's energy level is highest in the:
My pet's attitude and mood is best in the:
My is:
Check all that apply
What temperature does your pet seek to be?
My pet's sleep is:
My pet's dreams are:
My pet's mobility level is:
My pet's mobility is best in the:
Compared to 3 months ago, my pet's energy levels are:
Does your pet have a specific area that is weak or lame?
Is your pet in pain?
0 is no pain, with 10 being the worst
Is the pain better or worse after rest?
Is the pain better or worse after exercise?
My pet typically...
How often does your pet vomit?
What does your pet's stool look like?
Is there a strong odor to stools?
Does your pet have gas?
Your pet's thirst is:
How does your pet drink water?
How is your pet's urination?
What color is your pet's urine?
My pet has:
5
0 - My pet isn't itchy. 10 - Non-stop scratching.
Has your pet's hair coat changed?
My pet's breathing is:
My pet's voice or the noises that he/she makes are:
Does your pet seems stiff?
Check all that apply
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