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Referral form Fill up this referral form and e-mail to: Click to send the form once filled up [email protected] Fields marked * must be filled up Date: REFERRING VETERINARIAN INFORMATION NAME*: Dr. CLINIC: CONTACT E-MAIL*: PHONE: if you prefer to be contacted by phone, please indicate the best day and time CLINIC’S ADDRESS*: PATIENT INFORMATION PATIENT’S NAME*: SPECIES*: dog CLIENT’S LAST NAME*: BREED*: AGE*: SEX/NEUTER STATUS*: neutered male REASON FOR CONSULT: SUMMARY OF THE MEDICAL HISTORY*: Attach all necessary clinical information and send it to us along with this form: history, lab work (the most recent lab work) and other diagnostic tests CURRENT CLINICAL CONDITION*: Current clinical condition and final diagnostic 1 Referral form CURRENT MEDICATIONS: Include all current medications, dose, and length of treatment OTHER COMMENTS: List other important comments regarding the patient PATIENT’S NUTRITIONAL EVALUATION At the end of this form you can find the body and the muscle condition scores for your convenience BODY CONDITION SCORE*: score according to the attached scale 1 2 3 4 5 6 7 8 9 MUSCLE CONDITION SCORE*: score according to the attached scale Normal Mild Moderate Severe CURRENT BODY WEIGHT*: kg NORMAL BODY WEIGHT: Write the usual body weight that the patient has (or a body weight history, if available) ENVIRONMENT The patient lives: indoor outdoor Does the patient live with other pets? (specify them) 2 Referral form How much exercise does the patient get: Very little 2-3 walks per day, 20 to 60 minutes per walk Large backyard always available Long outdor walks/runs 1-2 times per week Other: FEEDING MANAGEMENT The patient: Has free and constant access to food Eats once a day Eats twice a day Eats three or more times a day Other: ¿Does the patient have access to other food sources? ¿Which ones? NUTRITIONAL RISK FACTORS Have you seen any of these changes in your patient? Weight loss Weight gain Decreased appetite/food intake Increased appetite/food intake Decreased thirst/water intake Increased thirst/water intake Other: If you have answered yes to any of the above, since when? Have you seen changes in stool quality? No Harder faeces Softer faeces Blood/mucus If you have answered yes to any of the above, since when? 3 Referral form Does the patient show Problems with mastication Problems with swallowing Food allergies/intolerances If yes, indicate to which ingredients: CURRENT DIET Please, indicate all the foods consumed daily by the patient, with detail and precision, in the table below. It is important to write the brand and amount fed of all commercial foods (including treats) that are currently being fed. Please include all products intended for human consumption that are fed as treats and table scraps. If your patient is eating a homemade diet, please specify the ingredients, cooking method, and amounts fed daily. Some examples are presented in the table. BRAND Affinity Advance TYPE Adult Medium Pollo y Arroz FORM DAILY AMOUNT FREQUENCY OF FEEDING SINCE WHEN IS THIS FED Kibble 200 grams Twice a day Since 3 years ago 150 grams Once a day Since 6 months ago Two pouches per day Twice a day 4 years ago after veterinary prescription Boiled chicken breast, meat only Royal Canin Renal Special Pouch 4 Referral form CURRENT SUPPLEMENTS Please, write down the nutritional supplements offered to the patient currently (or up to 3 months ago) (for example: joint supplements, fatty acids for the skin, etc), including dosage, since when are they fed and who prescribed them. e.g..: Cosequin, 2 tablets per day, since 6 months ago, prescribed by his veterinarian PREVIOUS DIETS AND SUPPLEMENTS Please, use the table below to list the brand and type of diets/supplements fed in the past, including period of administration, and reason for stopping. THIS IS PARTICULARLY IMPORTANT IN PATIENTS WITH SUSPECTED ADVERSE FOOD REACTIONS. e.g.: Royal Canin Hypoallergenic canine dry, January 2013 to March 2013, prescribed by veterinarian due to diarrhoea, stopped because diarrhoea did not improve. . e.g.: Eukanuba puppy dry, until one year ago, when the patient became an adult 5 Referral form If you request a homemade diet, please fill out the next section: TOLERANCE/PREFERENCE If you request a homemade diet indicate the ingredients tolerated and preferred by the patient. E.g.: chicken breast: tolerated and palatable If you have preferences for certain ingredients list them here: If you are requesting a weight loss plan, fill up this section: Regarding treats: Treats are not a part of the feeding plan I wish to include treats in the weight loss plan Specify the treats you would prefer to be included in the plan: Do you have any preference regarding the brand of the veterinary weight loss diet to be used? Thank you for your help, this information is very important to evaluate the patient and recommend the best nutritional plan for the patient 6 Global Nutrition Committee Toolkit provided courtesy of the World Small Animal Veterinary Association– available: http://www.wsava.org/nutrition-toolkit Referral form 7 Referral form 8 Referral form 9 Referral form 10