Acupuncture History Form Animal details Animal name * Age * Sex * Male Female Owner details First name * Last name * Address * Animal history details Please give as much detail as possible What problem(s) is your pet currently experiencing? What other health problems has your pet experienced? What do you feed your pet? Please list any medications and supplements your pet currently receives: Does your pet have any skin allergies or food intolerances/allergies? If so to what? What exercise does your pet do? What is your pet’s usual behaviour? (in relation to people, other dogs/animals in general. Any aggression? Any phobias etc) Breeding information: Have there been any changes in energy with your pet? Yes No What time of the day does your pet appear to have more energy? Or less energy? Please note if you have seen any of the following with your pet? Itching Head shaking Head rubbing Foot licking When did the current problem start to develop? Did it start in any particular season? Spring Summer Autumn Winter not apparent Did is start in any particular climate (please tick)? Cold Damp Hot Windy Dry not applicable Have you noticed a time of the day that the problem is worse? Is there evidence of pain? Yes No How long has pain been present for? If there is discomfort is your pet better for: Rest Exercise Heat Cold Massage No massage What things have you tried that help to reduce the pain (eg anti-inflammatories, Pentosan injections, swimming)? Does your pet prefer a warm or cold environment? ( ie she or he might like to lie on the cold tiles or follow sun spots around the house) Warm Cold Not noticeable How is your pet’s appetite ? Normal Increased Decreased Is there a preference for certain foods? Is he or she a picky or gutsy eater? Picky Gutsy Neither Is there a preference for warm or cold foods? Warm Cold No preference Have you noticed any belching? Any vomiting? Belching Vomiting How is your pet’s thirst? Increased Decreased Normal Do they prefer cold or warm water? (ie some animals prefer to drink when water has been sitting around for a while rather than straight from the tap as it is too cold) Warm Cold No preference Have you noticed a cough? Yes No Is there any hearing loss? Yes No Have you noticed changes in your pet’s vision? Yes No Is your pet's urination: Increased Decreased Normal Is there any incontinence, straining to urinate or dribbling of urine when trying to pass urine? Does your pet have a loud grumbly abdomen from time to time? Yes No Have you noticed any: Constipation Diarrhoea Mucus in stools Blood in stools What sort of sleeper is your pet? Sleeps solidly through the night Restless sleeper Is there much flatulence? Yes No When your pet is sleeping, do you notice: Movement Vocalisation When was your pet last in season? How long does season last? Bleeding: Heavy Light What is the time between seasons? How many litters have there been? Any problems with conceiving? The pregnancy ? Birthing process? If you are human, leave this field blank.
