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Acupuncture Intake Form
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Florence Animal Hospital
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Online Forms
Acupuncture Intake Form
Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.
Please enable JavaScript in your browser to complete this form.
Client Information
Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Patient Information
Name
*
Animal type:
*
Dog
Cat
Other
If other, please specify:
*
Age/Date of Birth
If date of birth is unknown, please write approximate age.
Gender:
*
Intact Male
Intact Female
Neutered Male
Spayed Female
Color/coat
Please list current medications, supplements, herbs, and preventative medications.
Please list your pet’s current diet including food, treats, and table scraps/human food (if any).
Are there any food or medication allergies or sensitivities?
No (or unknown)
Yes
If yes, please list below:
Main Complaint/Reason for Visit:
Previous medical history (conditions, injuries, diagnosis) or behavioral issues:
Please check all that apply and include additional information if available
Eyes
Discharge
Redness
Squinting
Vision Changes
Cataracts
Other
If other, please explain:
Ears
Discharge
Inflamation/Redness
Hearing Loss
Other
If other, please explain:
Nose
Discharge
Discolopration
Other
If other, please explain:
Mouth
Excessive tartar
Gingivitis (red gums)
Bad breath (halitosis)
Difficulty chewing
Excessive salivation
Other
If other, please explain:
Respiratory
Difficulty breathing
Excessive panting
Coughing
Sneezing
Nasal discharge
Other
If other, please explain:
Digestive
Vomiting
Diarrhea
Lack of appetite
Excessive appetite
Picky eater
Weight gain
Weight loss
Bad gas
Other
If other, please explain:
Skin/Hair coat
Dry
Greasy
Dandruff/flakes
Hair loss
Itchy
Sores/wounds
Other
If other, please explain:
Musculoskeletal
Back pain
Joint pain (arthritis)
Lameness/limping
Previous injuries
Joint swelling
Stiff/sore
Other
If other, please explain:
Activity
Increased activity
Decreased activity
Lethargic
Other
If other, please explain:
Urinary
Large amounts
Small amounts
Lethargic
Bloody
Increased frequency
Decreased frequency
Drinking more
Drinking less
Strong smell
Incontinence
Other
If other, please explain:
Feces
Loose/soft/watery
Dry
Constipated
Bloody
Increased frequency
Decreased frequency
Mucusy
Incontinence
Other
If other, please explain:
Sleep
Increased sleep
Decreased sleep
Restless sleep
Prefers soft bedding
Prefers hard surface
Other
If other, please explain:
Temperature
Prefers warm areas (sun, heater, blankets)
Prefers cool areas (cool tile, cement)
Other
If other, please explain:
Emotional
Depressed
Hyper excitable
Sociable
Hiding
Other
If other, please explain:
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