Acupuncture Service: New Client Questionnaire Patient’s NameDate of VisitMajor Complaint(s)Previous Medical History/ConcernsPrevious Diagnostics (blood work, x-rays, etc.): DescribeCurrent Medications/Supplements/Vitamins/HerbsHas your pet ever received TCVM/Integrative therapies in the past? Describe:Has your pet ever been diagnosed with a seizure disorder, heart disease, pregnancy or cancer? Describe:Please check all traits below which you feel apply to your pet:Personality: Outgoing Hyperactive Confident Alpha/Leader of the pack Aggressive/May bite Barks often/Very vocal Easily excitable ￼ Center of attention Loves being pet/handled Laid back/Easy going ￼ Aloof Obedient Introverted Barks often/Very vocal Patient Quiet Timid/Shy Fearful ￼Hides/Runs away Introverted Irritable Likes everyoneEnvironment Prefers cool locations(shade, concrete, tile) Prefers warm locations(sun, window sills, under blankets) Prefers hard surfaces(floors, tiles, kennel) Prefers soft surfaces(bed, carpet, blankets) Sleeps well at night Up and active at nightDiet Drinks a lot of water Normal water intake Good appetite, always hungry Poor appetite, finicky eater Prefers dry food Prefers wet food Affinity for cool foods: (ice, fish, cucumbers, watermelon, green beans) Affinity for warm foods: (chicken, pork, carrots, breads, pasta)Body Systems: Soft stools/Diarrhea Dry stools/Constipation Normal stool Blood in stool Mucus in stool Excessively malodorous stool Frequent flatulence/gas Burps often Loud digestion/GI noises Pants excessively Drools excessively Vomits/Regurgitates Ocular(eye) discharge Nasal(nose) discharge Vaginal/Penile discharge Dark urine Clear/dilute urine Normal urine Blood in urine Strong odor to urine Urinary leakage/IncontinenceHow did you hear about our services? Is there someone we may thank for referring you?