Integrative Medicine Medical History Form

Name: Animal Rehab Center of Michigan
Address: 1490 Lochaven Rd, Waterford, MI, 48327, United States
Telephone: 248-363-5061
Price range: $

Complete your form online!

Owner Name *

First

Last

Patient Name *

Species *

Dog
Cat
Other

Other

Breed

Sex *

Male
Female

Spayed or Neutered *

Date of Birth *

What is the main reason you are seeking acupuncture for your pet? Please describe previous and current health problems.

If your pet was treated previously for this problem, please answer the following questions:

What testing has been done and what were the results?

What treatments were utilized?

Did the pet show any improvement? If yes, please describe:

Since your pet’s last veterinary visit, is he/she the same, better or worse:

Please list to the best of your ability:

CURRENT MEDICATIONS including dose and frequency:

CURRENT HERBS AND/OR SUPPLEMENTS:

CURRENT DIET (including treats and table food):

CURRENT EXERCISE REGIMEN:

ALLERGIES TO MEDICATIONS OR FOOD:

Energy Level and Well-Being: Please choose most appropriate response:

Energy level in general:

Normal
Reduced
Increased

Energy is highest:

Morning
Afternoon
Night
Consistent

Attitude/mood is best:

Morning
Afternoon
Evening
Night
Consistent

My pet is:

Outgoing
Friendly
Relaxed
Hyperactive
Confident
Quiet
Timid
Shy
Fearful
Aggressive
Sad
Worried
Loyal

My pet is:

Happy
Content
Restless
Crabby
Depressed

My pet prefers:

To be cool
To be warm
Does not have a preference

Sleep:

Normal
Decreased
Increased
Restless at night

Dreams:

None
Vocalization
Running

Mobility: Please choose the most appropriate response

Mobility level:

Normal
Reduced
Increased

Mobility is best:

Morning
Afternoon
Evening
Night
Consistent

My pet has a specific area that is weak or lame:

If “YES”, please indicate all that apply:

Front right leg
Front left leg
Back left leg
Back right leg

Pain: Please circle or highlight most appropriate response:

My pet is in pain:

If “YES”, how long?

Please complete the following regarding your pet’s pain:

Pain is ___ / 10 with 10 being the worst

Selected Value: 0

Is the pain in a specific area?

best Fair, =

If "YES" please describe where:

After rest:

Better
Worse

After exercise:

Better
Worse

How does weather/temperature affect your pet’s pain?

Is there a time of day the pain seems better?

Morning
Afternoon
Evening
No difference

Nutrition/Digestion/Urinary: Please circle or highlight most appropriate response:

Appetite:

Normal
Increased
Decreased

My pet:

Loves to eat
Is not food motivated
Is picky

Vomiting:

None
Occasional
A couple times per week
Often
Other

If vomiting is a regular occurrence, please describe when it happens and what it looks like:

Stool:

Normal
Soft
Diarrhea
Hard and dry
Constipation
Incontinent
There is blood/mucous in the stool

Odor of stool:

Normal
Strong
No odor

Does your pet have gas?

Thirst:

Normal
Increased
Decreased

Water intake:

Frequent small sips
Large amounts at one time
Moderate

Urine:

Normal
Increased
Decreased
Incontinent
Straining
Vocalizes

Color of Urine:

Normal
Clear
Dark yellow

Odor of Urine:

Normal
No odor
Strong odor

Skin: Please circle or highlight most appropriate response:

My pet has:

Brittle nails
Dry pads
Dry skin with large flakes
Dry skin with small flakes

Is your pet itchy?

If “YES” please indicate which of the following apply:

Sometimes
During day
At night
All the time

Has your pet's hair coat changed?

If "YES", please describe:

Reproduction: Please choose the most appropriate response:

Fertile
Infertile
Not applicable

Describe any reproduction problems your pet has had:

Respiration/breathing: Please choose the most appropriate response:

Normal
Coughs
Has had a change in breathing

Describe:

Breathing is heavy
Strong
Weak
Shallow
Out of breath with exercise

My pet’s voice or noises that he/she makes are:

The same
Have changed

Describe:

General Medical Issues: Please choose the most appropriate response:

Separation anxiety
Heart problems
Insomnia
Thunderstorm (noise) phobia
Restlessness
Fever
Pants a lot

Problems with liver
Ligaments
Eyes
Nails
Footpads
Anal glands
Aggression
Seizures

Loss of appetite
Constipation
Diarrhea
Vomiting
Overweight
Gum disease
Weak muscles
Anxiety

Urinary issues
Back pain
Bone or growth issues
Weak in rear end
Fearful
Deaf
Reproductive problems
Arthritis
Teeth problems
Ear problems

Asthma
Sinusitis
Coughing
Breathing problems
Nose problems
Dry skin
Sneezing
Nasal discharge
Weak voice

Is there anything else we should know about your pet’s health or emotional history?

Rate your dog’s pain. (0-10, 0 = no pain, 10 = extreme pain)

a. Which one number best describes the pain at its worst in the last 7 days (0-10, 0 = no pain, 10 = extreme pain).

Selected Value: 0

b. Which one number best describes the pain at its least in the last 7 days (0-10, 0 = no pain, 10 = extreme pain).

Selected Value: 0

c. Which one number best describes the pain at its average in the last 7 days (0-10, 0 = no pain, 10 = extreme pain).

Selected Value: 0

d. Which one number best describes the pain as it is right now (0-10, 0 = no pain, 10 = extreme pain).

Selected Value: 0

Which one number best describes how during the past 7 days pain has interfered with your dog’s: (0-10, 0 = does not interfere, 10 = completely interferes)

a. General Activity (0-10, 0 = does not interfere, 10 = completely interferes)

Selected Value: 0

b. Enjoyment of Life (0-10, 0 = does not interfere, 10 = completely interferes)

Selected Value: 0

c. Ability to Rise to Standing From Lying Down (0-10, 0 = does not interfere, 10 = completely interferes)

Selected Value: 0

d. Ability to Walk (0-10, 0 = does not interfere, 10 = completely interferes)

Selected Value: 0

e. Ability to Run (0-10, 0 = does not interfere, 10 = completely interferes)

Selected Value: 0

f. Ability to Climb Up (for example Stairs or Curbs) (0-10, 0 = does not interfere, 10 = completely interferes)

Selected Value: 0

Which response best describes your dog’s overall quality of life over the last 7 days? (Bad, Fair, Good, Very Good Excellent)

Michigan's first rehabilitation center.

We are dedicated to providing excellent care.

Location

1490 Lochaven Rd
Waterford, MI 48327
Click here for directions.

Hours

Monday - Friday: 8am - 8pm
(By appointment only)
Saturday: 8am - 6pm
(By appointment only)

Contact Info

Phone: 248-363-5061
Fax: (248) 363-1138
Email: rehab@unionlakepets.com

We’re conveniently located in the parking lot of Union Lake Veterinary Hospital and Pet Services!

Note: Consultations and rehabilitation therapy sessions are scheduled by appointment only (see below). Referral from your veterinarian is preferred so that we may provide you with the most complete service!

Get in touch!

Name *

First

Last

Email *

Phone help we

Phone

How can we help you? *

Comment

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