Pet Information and Questionnaire

Your Name

First Last

Email

Pet's Name

Species

Dog
Cat

Breed

Gender

Pet's Date of Birth

Weight

Is your pet taking heartworm prevention?

Yes
No

If yes, which brand and how often?

Is your pet taking flea prevention?

Yes
No

If yes, which brand and how often?

Please list all medications and supplements that your pet is taking:

What brand of food do you feed your pet? Flavor or protein source? Canned vs dry? How much a day?

What kind of treats do you give your pet?

How is your pet's appetite?

Normal
Increased
Decreased

Describe your pets drinking habits?

Example: Large volumes at one time or smaller amounts often throughout the day?

Describe the stool character (solid, diarrhea, dry, any blood or mucus)?

Any gas?

Yes
No

Any belching?

Yes
No

Problems with vomiting?

If yes, please describe if it's associated with eating or a time of day and whether it is bile or food.

Any coughing?

If yes, does it occur at night, in the morning, during the day, more with activity/exercise/excitement, or no specific pattern noted?

How is your pet's overall energy level?

Does your pet have a preference for cool or warm temperatures?

For example, lying on tile or hardwood floor vs carpet, sleeping under the covers , curls up in a ball, sun bathing, sits next to a fire or space heater, etc.

Has there been any increase in panting?

Yes
No

Does your pet have trouble falling or staying asleep?

Yes
No

For example: pacing at night, restless while sleeping, vocalizing while sleeping, twitching, paddling of legs, dreaming

How's the overall emotional state (anxious, fearful, hyperactive, irritable, etc)?

What is the reason for your pet's visit?

Does your pet have any previous health issues?

Who is your current veterinarian?

CHINESE PET PERSONALITY

FIRE CONSTITUTION: Lively, very friendly, restless, hyperactive, communicative, loves to be center of attention, loves to be petted, scared for no reason, separation anxiety
WOOD CONSTITUTION: Confident, alpha animal, decisive, assertive, dominant, strong, implusive, angers easily, fearless
EARTH CONSTITUTION: Relaxed, laid back, sociable, cares for others (motherly), round & large, loyal, serene & balanced, over eats, worries
METAL CONSTITUTION: Loves order, obeys the rules, aloof, symmetrical body, disciplined, attitude
WATER CONSTITUTION: Careful, likes to hide, self-contained, fearful, slow and consistent, curious

I will use the information below to help formulate an Acupuncture, Herbal Medicine, and Food therapy treatment plan for your pet. Read through all the categories and check which constitution BEST describes your pet, knowing that they may have traits in more than one category.

Pet Information and Questionaire