Acupuncture Questionnaire

First Name*:

Last Name*:

Email Address*:

NorthStar VETS Location:

Robbinsville     Maple Shade

Patient Name*:

DOB:  

Breed:  

Gender:   F   FS    M   MS   

Weight:

Major Complaint

Please answer the following questions to the best of your knowledge. This will help in making an accurate diagnosis.

Preference:

Shade or cool locations (concrete, tile)     Sun or warm locations (heatregister, carpet, blankets)

Personality:

Hyperactive, outgoing, strong, confident     Quiet, timid, shy, less confident

Thirst:

Increased thirst     Decreased thirst

Appetite:

Good or ravenous, unchanged    Finicky, decreased

Feces:

Dry, bloody, malodorous (smelly)     Loose, diahrrea, little odor

Urine:

Shorter stream, malodorous, bloody     Longer stream, urinary leakage

Duration:

Short, recent     Long, chronic

Breathing:

Heavy, panting     Long, labored

Sleep:

Increased/too much     Decreased/too little (restless, pacing, muscle jerking)

Exercise:

Same/Increased     Decreased/intolerant/tires easily

Stiffness:

Acute onset     Chronic

Worse:

in morning    in evening   
with cold    with heat    in damp   
after walk   before walk

Massage/touch:

Likes (enjoys/allows)     Dislikes (will not allow/growls)

Vomiting:

Frequent     Sporadic
Specify
Large amount     Small amounts
Undigested food     Fluid only     Soon after eating

Voice:

Loud     Weak

Check the box below