Species:
Equine
Sex

I. What is your horses’ main reason for seeking/needing acupuncture?

II. If your horse was treated previously for this problem, please answer the following questions:

Since your horse’s last veterinary visit, is he/she

III. Please list to your best ability:

IV. Traditional Chinese Medicine (TCM) history: (in each section, please answer or circle all that apply)

Energy and Well-Being:

Energy level in general
Energy is highest
Attitude/mood is best
My horse is:
My horse is:

Mobility

Mobility level
Mobility is best
My horse has a specific area that is weak or lame
If “Yes,” please circle all that apply:
My horse has received joint injections

Pain

My horse is in pain:
If you answered “Yes,” please complete the following regarding your pet’s pain:
Is the pain in a specific area?
After rest, the pain is
After exercise, the pain is
The pain is

Nutrition/Digestion/ Urinary:

Appetite
Stools
In the stool there is
Odor of stool
Does your horse have gas?
Thirst
Water intake
Urine
Color of urine?
Odor of urine?

Skin:

My horse’s hooves are:
Dry Skin type
Is your horse itchy?
If “Yes” please circle all that apply:
Has your horse’s hair coat changed?

Reproduction:

My horse is:

Respiration/breathing:

My horse is:
This field is for validation purposes and should be left unchanged.