Nutrition Consultation Questionnaire TOPS

Nutrition Consultation Questionnaire
General Information
Date

MonthDayYear
Date
Owner Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about nutritional consults at TOPS?
Would you like us to send our nutrition records to your veterinarian?*

YesNo
If so, please provide the Clinic Name, Name of Veterinarian, Phone #, Fax #
Pet Name*
Date of Birth*
Sex*

MaleFemale
Breed*
Neutered/Spayed*

YesNo
Current Weight*
Current diet (type and amount):*
Current treats (type and amount):*
Major medical history:*
Current Medications:*
Current Supplements:*
Diet History
In your opinion, what type of food has your pet seemed healthiest on in the past?*
How has your pet reacted in the past with diet changes?*
How long do you usually take to change the diet (ex: immediately, 1 week, 2 weeks)?*
Are you aware of any food sensitivities with your pet? If so, please list these sensitivities and the reactions you have observed.*
Have you ever tried to supplement probiotics into the diet? If so, what brands have you tried?*
Bowel Movements: We can tell a lot about the health of your pet’s gastrointestinal tract by looking at the different qualities of his/her bowel movements.
What is the typical consistency of your pet’s stool?*
Have there been any changes in stool consistency? If so, please explain.*
How many times per day does your pet defecate?*
Activity
How active is your pet? Please explain the type and frequency of any activity/exercise your pet does: *
Traditional Chinese Veterinary Medicine (TVCM) is another modality we can incorporate into nutritional consultations. It involves addressing how the energetics of food can influence body function and overall health.
Are you interested in exploring this modality and possibly incorporating it into your pet’s nutritional consultation?*

YesNo
Goals/Preferences:
What are your goals with pursuing a nutritional consultation?*
What are your and/or your pet’s diet preferences? (ex: raw, cooked, kibble/dry food, canned) Why?*
Should be Empty:

Nutrition Consultation Questionnaire

General Information

Diet History

Activity

Goals/Preferences: