Acupuncture History Form

We offer Traditional Chinese Veterinary Medicine to help your pet.

Thank you for choosing us.

Our veterinarian is highly trained in acupuncture and Traditional Chinese Veterinary Medicine. We look forward to helping and healing your pet.

Acupuncture History Form

Please fill out the following form as thoroughly as possible before your appointment. Please note: all * fields are required.

Caregiver's Name *

First

Last

Caregiver's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Caregiver's Phone Number *

Caregiver's Email Address *

Patient's Name *

Patient's Age and/or Date of Birth *

Species *

Patient's Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Diet *

Treats

Prevention (heartworm/fleas/ticks) *

Medication(s) *

Supplement(s)

Please describe your pet’s general history, including how long you’ve had them, if they were adopted or purchased, if there have been any significant changes in the pet’s life, if there have been any significant medical issues in the past, etc: *

Please describe your most significant reasons for consulting a veterinary acupuncturist and your main concern for your pet. Please include how long this concern has been going on: *

For the following Symptoms or Clinical Signs, please indicate whether you think it is. *

Normal
Increased
Decreased
None
Other Issue

If other, please explain. *

Voice (barking or meowing): *

Activity Level: *

Sleep: *

Food Intake: *

Water Intake: *

Stool (defecation): *

Urination: *

Vomiting: *

Cough: *

Stiffness (in joints): *

How would you describe the following in your pet's activity? *

Prefers to lay in the shade and on cool surfaces
Prefers to lay in the sun and on warm surfaces

How would you describe the following in your pet's personality? *

Is hyperactive, outgoing and confident
Is quiet, timid, and less confident

How would you describe the following in your pet appetite? *

Has a ravenous appetite
Is a picky/finicky eater

How would you describe the following in your pet's stool? *

Has feces that is dry
Has feces that is wet

Please also describe if any loose stool, diarrhea, blood, odor, etc

How would you describe the following in your pet's urine? *

Has short streams of urine
Has long streams of urine

Please also describe any odor, blood, or leakage

Please make any additional comments here

Your preferred Wellington veterinary hospital

When you bring your pet to our veterinary clinic in Wellington, FL, you’re trusting their health and care
to the very best the Wellington area has to offer.

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Location

11320 Fortune Cir, Ste G1-G2
Wellington, FL 33414

Contact Us

P: 561-345-2537
F: 561-409-5769
E: [email protected]

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Hours

Monday - Friday
8:00 AM - 5:00 PM

Contact Us

Because if we can’t resist the looks your pets give us, why should you?

Name *

First

Last

Email *

Phone

How can we help you? *

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