Initial Acupuncture Form Your Name(Required) First Name of Pet(Required) First Birthday(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Species Sex Male Female Breed Color WeightPrimary Care Veterinarian Were you referred? Has your pet been seen by any other veterinarians for this problem? If so, please list the practice name as well as the veterinarian below.Has your pet had any diagnostic imaging done for this problem? If diagnostic imaging was done, please tell us where.What are your primary reason(s) and goal(s) for coming to East Bend Animal Hospital?What does your pet eat? (Please indicate kind(s) and form(s), such as brand, primary protein source (Chicken, Fish, Beed, etc.) kibble, canned, etc., amount of food, include treats.Does your pet currently require assistance for normal activities (walking, getting up, getting into car, positioning for urination and/or defecation, etc.)? Please explain as much as possible.What is your pet’s current activity (frequency and length of walks, etc.)?What type of flooring do you have in your home? Is your pet slipping or having trouble getting up on slick surfaces such as hardwood/tile? Are there any stairs your pet much maneuver daily and, if so, do they have difficulty? What supplements does your pet currently receive (Such as joint supplements, vitamins, fish oils, etc. Please include brands, amounts, etc.)?What medications does your pet receive (including all prescribed and routine medications such as heartworm prevention, flea/tick prevention, etc.)? Please include brand and doses.Are there any time constraints that we should be aware of for the future for working with your pet? Please be sure that we have received you pet’s medical records from your primary care veterinarian. We need to have these to combine with our physical examination findings to enable us to develop the most accurate diagnosis and formulate the finest therapeutic plan for your pet. (Some hospitals will not release a pet’s medical record without the owner/pet parents’ consent.) Δ
