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Dr. Rachael Baldwin

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Intake Form

Please fill out this form and email records to info@TulsaVeterinaryAcupuncture.com at least 48 hours prior to your visit. This allows us to have more time with you and your pet during the appointment. If this is not received prior to the exam you may be asked to reschedule.

Contact Information

First name

Last name

Pet's name

Email

Phone

Address

Pet's age

Pet's weight

Pet's breed (if known)

Pet's sex

Female

Male

Spayed/ Neutered

Yes, my pet is spayed or neutered.

No, my pet is not spayed or neutered.

Health History

Who is your primary veterinarian?

What conditions has your pet been diagnosed with?

What medications is your pet taking? Please include any heartworm, flea, or tick medications and over-the-counter medications and supplements.

What concerns do you have about your pet's health?

What food is your pet eating?

How is your pet's appetite?

Normal for my pet.

Eating more than usual.

Eating less than usual.

If your pet's appetite is abnormal, please explain.

How is your pet's water intake?

Normal for my pet.

Drinking more than normal.

Drinking less than normal.

If water intake is abnormal, how long have you noticed the change?

Is your pet vomiting?

Yes

No

If yes, how often?

Is your pet having diarrhea?

Yes

No

Is your pet coughing?

Yes

No

Does your pet spend more time inside or outside?

Inside only.

Outside only.

Both inside and outside.

How is your pet's activity level?

Normal for my pet.

Activity level is increased.

Activity level is decreased.

How are your pet's sleep habits?

Normal for my pet.

Sleeping more than normal.

Sleeping less than normal.

Does your pet have a temperature preference?

My pet prefers/ seeks out cooler temperatures and tends to get too hot.

My pet prefers/ seeks out warmer temperatures and tends to get too cold.

My pet does not appear to have a temperature preference.

Personality/ Behavior

The following questions may sound a little silly, but they are meant to help us better understand your pet's personality and behavior. There are no wrong answers.

If my pet were a person at a party, he/ she would be:

The life of the party - friendly, affectionate, likes being the center of attention, extroverted.

The host or nurturer - likes to take care of others, relax, take their time, and enjoy the party. This is a go-with-the-flow type of personality.

The boss or judge - enforces structure and etiquette, likes rules and organization, know what they want but may also think they know what other people want or should want.

The observer - may be hiding in a corner observing at first before socializing, introverted, shy or even fearful.

The initiator/ energizer - may organize activities for everyone to do, takes more of a leadership role, knows what they want and what they don't want.

Which characteristics describe your pet. Choose all that apply.

friendly

dominant

aggressive

competitive

confident

fearless

adaptive

intolerant

irritable

stressed by changing conditions

easily excited

extroverted

playful

sensitive

difficult to calm down

talkative or noisy

enjoys attention

enjoys physical contact

hyperactive

anxiety

restless

laid back/ easy going

sweet

slow moving

easily satisfied

kind

tolerant

excessive worry

overweight

aloof

independent

organized

quiet

consistent

depressed attitude

shy

introverted

solitary

hesitant

fearful

observant

withdrawn

Does your pet have issues in any of the following areas?

tendon or ligament

liver or gallbladder

eye problems

seizures

allergies

high blood pressure

heart disease

anorexia

vomiting

diarrhea

constipation

gum or lip problems

nasal congestion or discharge

upper airway infection

cough

kidney or bladder problems

arthritis

disc disease

back pain

Is there any other information you would like us to know before your appointment?

Dr. Rachael Baldwin

(918) 732-9569

info@TulsaVeterinaryAcupuncture.com

Tulsa, OK

Your Pet's Health Matters

Name

Email

Questions? Let us know how we can help!

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