Acupuncture Form | Quioccasin Veterinary Hospital in Richmond, VA

Client/Patient Questions

Patient name/owner name:(Required)

Major Complaint/Concern:(Required)

Duration of symptoms:(Required)

Western Diagnosis:(Required)

Current treatments and medications:(Required)

How long has the patient been receiving these treatments or medications?(Required)

Do you feel his/her symptoms or quality of life has improved with treatments/medications?(Required)

Past medical problems:(Required)

Diet (amount, brand, how often fed):(Required)

Describe appetite-eats well, finicky, etc.:(Required)

Thirst: (drinks a lot at one time, drinks little sips all day, etc.)(Required)

Vomiting: ( over lifetime and currently, does patient have ongoing or intermittent vomiting?)(Required)

Diarrhea: (over lifetime and currently, does patient have ongoing or intermittent diarrhea?)(Required)

Constipation: (over lifetime and currently, does patient have ongoing or intermittent trouble with constipation?)(Required)

Urination habits: (amount, dribbling, accidents in house, infections, frequency of urination per day, odor, etc.)(Required)

Are there other pets in the household? What type and how many?(Required)

What is the overall energy/stamina level of your pet currently?(Required)

Interactions of patient with other pets and humans:(Required)

Personality: (bossy, aggressive, out-going, friendly, laid-back, easy-going, aloof, quiet, timid, fearful)(Required)

Preference for temperature: (cold, warm, neutral)

Likes to sleep on cool tile or warm carpet?(Required)

Cool tile

Warm carpet

Pants even when in air-conditioning?(Required)

Yes

Likes to lay in the sun even when it is hot?(Required)

Yes

Easily adapts to surrounding temperature?(Required)

Yes

Seems to be intolerant of heat?(Required)

Yes

Seems to be intolerant of cold?(Required)

Yes

Sleep

Likes to sleep on the hard floor?(Required)

Yes

Likes to sleep on a soft bed?(Required)

Yes

Once asleep at night, stays asleep? Wakes up? Restless?(Required)

Confidence/fearfulness

Startles easily with loud noises or sudden movements?(Required)

Yes

Reaction to new situations or people?(Required)

Yes

Overall emotional state currently (anxious, laid-back, aggressive, irritable, bossy, etc.):(Required)

What overall observations would you make about him/her (likes to be fussed over, clingy, indifferent, etc.)?(Required)

Any expression of aggression now or in the past? If so, what were the circumstances?(Required)

Personality types of TCVM

Each animal, and human, is a combination of all 5 elements. However, each of us has a predominant element that defines us. See if one of these describes your dog or cat’s personality more than the others.

Fire: extremely friendly, greets strangers warmly, noisy/barking/talkative/excited/hyperexcitable, center of attention, difficult to keep still, sensitive to needles, extremely extroverted.

Wood: arrogantly confident, irritable/crabby, active/energetic/athletic. Aggressive/angryr, competitive, bites with little provocation, impatient, extroverted.

Earth: friendly, enjoys sleeping and eating, eager to please owner, slow to react, laid-back, easy-going, worries for others, extroverted or introverted.

Water: fearful, quiet, not confident, watches what the vet is doing, normal or nervous in the exam room, but aggressive at home. Extremely introverted.

Metal: aloof, quiet, confident but not arrogant, disciplined, follows the rules, organized, hides emotions, introverted.

Thank you for taking the time to help me know your furry family member better! I look forward to working with you!

Sincerely,

Carroll Garland

Certified Veterinary Acupuncturist, DVM

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