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Love Pet Hospital 8106 Brodie Lane Suite102 Austin, TX 78745 (512) 282-0221

Home Acupuncture and Herb Consult Please list previous medical history(severe illness and trauma) please include dates: Description: Date:   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD01020304050607080910111213141516171819202122232425262728293031 YYYY 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD01020304050607080910111213141516171819202122232425262728293031 YYYY 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD01020304050607080910111213141516171819202122232425262728293031 YYYY 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 What is the current health or behavior problem?   Is there any pain in the body? If so can you list where?   Does your pet prefer heat(lays in sun/on bed) None Yes No cold(tile floor) None Yes No Appetite: Poor Fair Good Thirst: Little Normal Excessive Sleep: Good Disturbed or Anxious at night Urination: Frequently & a lot Frequently & a little Normal Strong odor Normal odor Stools: Formed Loose Alternates   Hard & sometimes constipated       Strong odor Normal odor/not much smell Vomits: Never or Rarely Daily Weekly   Food Bile(yellow) White Foam   Strong odor Normal odor/not much smell Predominate Emotions: Fearful Worried Depressed   Sad Happy & full wagging a lot   Dominant & something aggressive Any emotional upset in the family recently: Yes No Hearing: Normal Reduced       Deaf, if yes how long? Vision: Normal Reduced       Blind, if yes how long? List all current medications and dosages: List all nutritional supplements on herbs currently giving and dosages: What diet does your pet eat:: How much How often Does your pet have any current blood profiles or x-rays: Yes No Are you interested in these diagnostic tools, if the Doctor feels they are necessary:: Yes No Any additional information, you feel is important: