Download Diet history form - Vets Now Referrals

Nutrition Service - Diet History Form
Pet Name: _______________
Dog or Cat?
Client Name______________
Breed_________________
Age____________
Date:____________
Clinic name and address: ______________________________________________
Clinic phone number:__________________________________________________
Reason for consult:
Current weight _________kg
Ideal weight ___________kg
BCS ________/9_____ Sex: Male Female
1. Is the pet housed (circle or underline):
for walks or exercise
Neutered: Yes No
Indoor Outdoor
Both
Outside mainly
2. Please describe pet’s activity level (i.e. type, duration, frequency)
3. Does the pet live with other dogs or cats? No Yes
Please list: ________________
4. Is the pet fed in the presence of other animals? No
Yes
5. Is feed left out for your pet during the day or taken away after the meal?
Out Away
6. Does the pet have access to other unmonitored food sources, e.g. food from a
neighbour, access to outdoors, other pet’s food? No Yes, if yes please describe:
7 Who typically feeds the pet?
8. How is the pet’s food stored?
9. Please list any current or past medical problems and if they have resolved:
10. Please list all the medications the pet is currently receiving and any administered
over the past three months (indicate medications that are current):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
11. Please indicate whether the pet has experienced any of the following before
today’s visit:
Recent involuntary or unintended
 weight gain OR  weight loss
How much? __________________kg or lb
Over what time period? ________________
 Vomiting
____________ times/day _____________ times/week
 Diarrhoea ____________ times/day _____________ times/week
12. Have there been any observed changes in any of the following?
 Urination OR  Drinking
What was the specific change?
______________________________________________________________
Since when?
______________________________________________________________
 Defecation What was the specific change?
______________________________________________________________
Since when?
______________________________________________________________
 Appetite What was the specific change?
______________________________________________________________
Since when?
______________________________________________________________
13. Does the pet have?  allergies OR difficulty  chewing  swallowing
If so, please describe: ____________________________________________
Current Diets
Please list below the brand or product names (if applicable) and amounts of ALL
foods, snacks, and treats the pet currently eats. Please separate out each ingredient
in a home-cooked diet, listing each ingredient on its own line. This description should
provide enough detail that we could go to the store and purchase the food. It should
include human foods given as treats or at the table. Examples are given in italics.
Brand/Product/Food Form
E.g. Brand Name
Dog Chow
E.g. Boneless
Chicken
# of Meals
Fed Since
Dry
Amount fed
per meal
1 ½ cups
Twice a day
May 2010
Boiled
2 ounces
3 times a
week
June 2014
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Previous Diets
Please list other diets and treats the pet has received in the past, indicating the
approximate time period when they were fed. An example is given in italics.
Brand/Product/Food Form
E.g. Brand Name
Kitten Diet
Can
From
June 1999
To
March 2011
Reason
Stopped
Became adult
Please list the name of each additional supplement the pet receives, indicate how
much and how often your pet receives it (i.e. herbal product, fatty acid, vitamin or
mineral supplement):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Pet Dietary Preferences/Restrictions: (What ingredients will/can your pet eat?)
Please fill out this section ONLY if a home-cooked diet formulation is being
requested or may be needed. If diet formulation is needed due to an adverse
reaction to food(s), please provide us with some options of protein and
carbohydrate sources that are both palatable AND tolerated by this animal.
This will need to be determined prior to submitting this consult.
Protein Sources
Carbohydrate Sources
 beef
 pork
 barley
 potato, white
 chicken
 salmon
 couscous
 bread
 cottage cheese  tofu/quon
 oatmeal
 rice, brown
 crab
 tuna
 pasta, spaghetti
 rice, white
 egg
 turkey
 peas, green
 tapioca
 lamb
 whitefish
 potato, sweet
 corn
 other (please specify):
________________________________________________________________
________________________________________________________________
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