Patient Name Owner's Name Species: EquineBreed DOB or Age Sex Mare Stallion Gelding I. What is your horses’ main reason for seeking/needing acupuncture?a. Health Problem(s), describe:b. General WellnessII. If your horse was treated previously for this problem, please answer the following questions:What diagnostics have been done and what were results? (ex. Bloodwork, X-rays)What treatments were utilized?Did the horse show any improvement? If so, please describe:Since your horse’s last veterinary visit, is he/she the same better worse III. Please list to your best ability:CURRENT MEDICATIONS:CURRENT HERBS AND/OR SUPPLEMENTS:CURRENT DIET:CURRENT EXERCISE REGIMEN:IV. Traditional Chinese Medicine (TCM) history: (in each section, please answer or circle all that apply) Energy and Well-Being: Energy level in general normal reduced increased Energy is highest morning afternoon night consistent Attitude/mood is best morning afternoon evening night consistent My horse is: Outgoing Shy Aggressive My horse is: Happy Content Restless Crabby Depressed Mobility Mobility level normal reduced increased Mobility is best morning afternoon evening night consistent My horse has a specific area that is weak or lame yes no If “Yes,” please circle all that apply: Front right leg Front left leg Back right leg Back left leg My horse has received joint injections No Yes If “yes” which joints Pain My horse is in pain: No Yes If Yes, How long? If you answered “Yes,” please complete the following regarding your pet’s pain:Pain is ___/10 with 10 being the worst Is the pain in a specific area? No Yes Where? After rest, the pain is Better Worse After exercise, the pain is Better Worse How does weather/temperature affect your horse’s pain? The pain is Better in am better in afternoon better in evening no time difference Nutrition/Digestion/ Urinary: Appetite normal increased decreased Stools normal soft diarrhea hard and dry constipation incontinent In the stool there is blood mucous Odor of stool normal strong no odor Does your horse have gas? Yes No Thirst normal increased decreased Water intake Frequent small sips large amounts at one time moderate Urine normal increased decreased Incontinent Straining Color of urine? Normal clear dark yellow Odor of urine? Normal no odor strong odor Skin: My horse’s hooves are: normal thin walled difficult to keep shoes on grow slowly How often reshod or trimmed? Dry Skin type dry skin with large flakes dry skin with small flakes Is your horse itchy? No Yes If “Yes” please circle all that apply: sometimes during day at night all the time summer winter Has your horse’s hair coat changed? No Yes Describe Reproduction: My horse is: fertile infertile not applicable Describe any reproduction problems your horse has had: Respiration/breathing: My horse is: normal coughs has had a change in breathing DescribeIs there anything else we should know about your horse’s health or emotional history?EmailThis field is for validation purposes and should be left unchanged.