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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 Page 2 of 3 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): ________________________________________________________________ ________________________________________________________________ Page 3 of 3