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Acupuncture Intake Form

First Name

Last Name

Email

Phone

Address

Pet Name

Weight

Species

Is your pet anxious or have trouble with vet visits

Breed

Age

What is your main concern you would like to address during our sessions?

Does your pet have any medical conditions or is your pet on any medications?

Appetite

Increased

Normal

Decreased

Historically a picky eater

Wate Intake

Increased

Normal

Decreased

Rarely drinks water

Feces

Soft

Firm

Watery

Mucous

Constipated

Bloody

Accidents in the home

Cough

Dry

Loud

Worse in the evening

Weak or soft

Morning

Urination

Accidents or incontinence

Malodorous

Short stream

Prolonged stream

Bloody

Vomiting

Undigested food

Once a week

After eating

Infrequent

Voice

Strong

Weak

Respiration or breathing patten

Panting or rapid

Shallow

Normal

Appetite

Increased

Normal

Decreased

Historically a picky eater

Select all that apply

Sleeps most of the time

Prefers cold surfaces

Seeks warmth

Difficulty sleeping

Anal gland problems

Anxious

Fearful

Laid back

Dominant

Poor hearing or deaf

Decreased vision

Select all that apply

Loves being pet or touched

Loyal

Food motivated

Vocal

Indifferent to touch or affection

Hyper

Sore or stiff

Difficulty sleeping or wakes you up at night

Hides or fearful

Ear problems or infections

Thanks for submitting!

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