Welcome to our acupuncture questionnaire. Please complete this form at least 24 hours prior to your appointment to allow Dr CastaƱeda ample time to review your answers.

Owner's Name
Pet's Name
Please write your pet's breed, sex & date of birth
Why are you seeking acupuncture services for your pet?
What are you hoping acupuncture will do for your pet?
Age when pet was acquired?
Where did you acquire your pet (e.g.breeder, stray, pet store, shelter)?
Why did you choose this individual pet?
What other pets are in this household? If yes, do they get along?
Greeting Strangers
Other Notable Characteristics (Check all that apply)
What is your pet's current specific medical problem?
Please list all major health problems that your pet has had in the past.
List any treatments being used to treat the current medical problem. Be sure to include any conventional (e.g.. surgeries, antibiotics, steroids) or holistic therapies (e.g. chiropractic, herbs, supplements).
How is your pet's elimination? Particular smell? Dry or loose stools? Urinary incontinence?
Do you use Flea/Tick prevention on your pet? If so, what kind and how often?
Please list your pet's vaccine schedule, including the frequency of vaccination (e.g. every year, every 3 years)
What specifically does your pet eat (e.g. home-prepared, raw, kibble, canned)? How often? What is the quantity of food fed at each meal?
How long have you been feeding this diet?
How is your pet's appetite? Good, ravenous, finicky?
Would you be willing to cook food for your pet?
What kind of treats does your animal eat (include everything)?
Does your pet have any kind of dietary sensitivities or food allergies?
Does your pet have any unusual cravings (e.g. grass, dirt, rocks, feces, plastic, metal)?
How is your pet's level of thirst? Have there been any recent changes?
Have there been any major changes in the pet's household environment (e.g. moving, marriage, death of another pet or human, divorce, new pet, new children)?
How would your describe the household environment for your pet (e.g. calm, stressful, chaotic, mellow, lonely, crowded)
Describe your pet's sleep habits. Where does (s)he sleep? Does (s)he move from place to place during the night?
How does your pet get exercise (e.g. leash walks only, beach, park, agility)? How often?
Describe your pet's activity level. Does (s)he tire easily? Never seems to tire?
Does your pet have free access to the outdoors?
Describe a typical daily schedule for your pet.
Please list all the people and animals currently living in the household.
Does anyone in the household receive holistic medical treatments (e.g. acupuncture, chiropractic care, massage, supplements)? If yes, please describe further.