Your Name *

First

Last

Species *

Dog
Cat

Breed

Sex *

MN
M
FS
F

Diet

Treats

Prevention (Heart worm, fleas, ticks):

Medications:

Supplements:

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 pursuing veterinary acupuncture 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.

Voice (barking or meowing):

	Normal	Increased	Decreased	None	Other Issue
Activity Level:	NormalActivity Level: Normal	IncreasedActivity Level: Increased	DecreasedActivity Level: Decreased	NoneActivity Level: None	Other IssueActivity Level: Other Issue
Sleep:	NormalSleep: Normal	IncreasedSleep: Increased	DecreasedSleep: Decreased	NoneSleep: None	Other IssueSleep: Other Issue
Food Intake:	NormalFood Intake: Normal	IncreasedFood Intake: Increased	DecreasedFood Intake: Decreased	NoneFood Intake: None	Other IssueFood Intake: Other Issue
Water Intake:	NormalWater Intake: Normal	IncreasedWater Intake: Increased	DecreasedWater Intake: Decreased	NoneWater Intake: None	Other IssueWater Intake: Other Issue
Stool (Defecation):	NormalStool (Defecation): Normal	IncreasedStool (Defecation): Increased	DecreasedStool (Defecation): Decreased	NoneStool (Defecation): None	Other IssueStool (Defecation): Other Issue
Urination:	NormalUrination: Normal	IncreasedUrination: Increased	DecreasedUrination: Decreased	NoneUrination: None	Other IssueUrination: Other Issue
Vomiting	NormalVomiting Normal	IncreasedVomiting Increased	DecreasedVomiting Decreased	NoneVomiting None	Other IssueVomiting Other Issue
Cough:	NormalCough: Normal	IncreasedCough: Increased	DecreasedCough: Decreased	NoneCough: None	Other IssueCough: Other Issue
Stiffness (in joints):	NormalStiffness (in joints): Normal	IncreasedStiffness (in joints): Increased	DecreasedStiffness (in joints): Decreased	NoneStiffness (in joints): None	Other IssueStiffness (in joints): Other Issue

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’s appetite? *

Has a ravenous appetite
Is a picky/finicky eater

How would you describe the following in your pet’s stool: *

Feces are dry
Feces are we

Please also describe if any lose stool, diarrhea, blood, odors etc:

Please share any additional information you think is important about your pet:

Please check all that apply to your pet

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Consent for Acupuncture Procedure(s), Package and/or Treatment I authorize Treehouse Animal Clinic’s (also referred to as “TAC”) veterinary staff to perform Acupuncture and Acupuncture related medical procedure(s) and/or treatment(s) on my pet. I acknowledge and understand that unknown and unanticipated risks and complications could arise from the acupuncture session and that will not relieve me of any obligation to all reasonable costs incurred regarding my pet. I indicate with my signature my consent to the Acupuncture procedure(s), that all questions have been answered to my full satisfaction and that I understand any risk associated with my pet’s procedure(s).

ADDITIONAL SERVICES: We will not offer any additional services while pets are here for their acupuncture session in order to create a positive environment and experience.

PAYMENT DUE AT TIME OF SERVICE: We accept American Express, Visa, Mastercard, Discover, Debit, Cash or Check only. We do not accept Care Credit or Payment Plans.

Signature *

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Best phone number to be reached if dropping off *

Date *

Acupuncture Questionnaire and Consent Form