FHA Diet History/ Questionnaire

FHA Diet History/ Questionnaire

In order for the FHA Nutrition Service provide optimal nutritional recommendations and guidelines, please fill out the form below with as much detail as possible.
Please fill out each section of the form and submit.

Please allow 20-30 minutes to fill out this form.

This form does have the ability to save and return later to finish it but please don't forget as we cannot move forward with scheduling until we have it completed.

This form will be used by our team to help make recommendations for your pet. Pertinent information will be shared with your referring veterinarian.

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Current Pricing:

New client appointment: $358

Homemade diet recipe (per recipe, includes 30-min recheck): $316

Other services available as add-ons for additional fees.

Your doctor can speak more to you about these in the appointment.

*Prices subject to change as hospital-wide pricing changes*

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PLEASE NOTE:

We operate only on a referral basis. Your veterinarian MUST fill out a referral form and send medical records prior to establishment with our service.

We CANNOT give medical advice or write prescriptions for pets we have not seen for an initial consultation.

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*** Dr. Luisana's schedule is currently closed until further notice. ***
**We are scheduling on Dr. Bullen's schedule only. **

We are currently scheduling 2-3 months out for all non-emergent appointments.

CLIENT INFORMATION
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Phone Number*
Please enter a valid phone number.
INTERNATIONAL CLIENTS: if you have an international phone number, please type it below (including country code)
Please do NOT just enter which country you're in, thanks!
Email (please double check your email address as this is our primary form of communication)*
How did you find out about the Nutrition service at Friendship Hospital for Animals (FHA)?*

PET INFORMATION
Pet Name*
Canine/Feline?*

CanineFeline
My animal is:

Under 1 year old currentlyOver 1 year old currentlyOver 10 years old currentlyOver 15 years old currently
Breed*
Pet Gender/Neuter Status*
Coat Color*
Age*
Birthdate (if known)

MonthDayYear
CLIENT EXPECTATIONS

At Friendship Nutrition, we feel that in order to have a productive and meaningful relationship, mutual respect and kindness are expected from us and you, our wonderful clients.

Just some quick notes to make the whole process a bit smoother:
- Our primary form of communication is via email so please plan to send emails rather than calling in as our medical staff is not on site. We are not set up to text or fax.
- If you've sent in your Intake Form and haven't heard from our team, feel free to reach out and request an update on where we are in the scheduling process. (Often, vets are faster about their form if you can call and notify them to be on the lookout for the Referral Request from us. We will send them their form directly).
- If you have not received your notes/plan, it is your responsibility to reach out for an update.
- It is your responsibility to reach out to your other vets to make sure we get full medical records and labs for the duration of our partnership (If you get new labs, for example, please make sure to have a copy forwarded to us).
- While it is our pleasure to help you and your pets, we are a support service and operate mainly via teleconsulting, which is not appropriate for urgent concerns. If you have urgent concerns regarding your pet, please reach out to your primary (or referring) veterinarian or an emergency clinic and do not wait for a email/call back.

VETERINARIAN INFORMATION (primary clinic the pet sees)
Hospital/Clinic Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor (if known, or say "multiple")
Clinic City & State
Clinic Email*
This should be a clinic email we can reach out to for records and to speak to clinic staff.
Clinic Phone Number*
Please enter a valid phone number.
INTERNATIONAL CLINICS: Clinic Phone number (with country code)
Please do NOT just enter which country you're in, thanks!
If you have other clinics we need to contact for records, please let us know the clinic NAME and clinic EMAIL below (Please write N/A if no answer):*

DIETS/SERVICES INFORMATION
DESIRED SERVICES (choose all that apply)*

General consultation/ guidanceCommercial (may include prescriptive) dietary recommendations/ feeding guidelinesTailored homemade diet formulation and feeding guidelinesTailored weight loss treatment planSupplement discussion/ evaluationAnalysis of current commercial diet(s)Analysis of current homemade diet(s)I’m not sure yet…Other
If you checked "Other" Please describe/specify:
Overall Goals and Concerns: Please summarize your pet's dietary history - including your greatest goals for your nutrition consultation and your greatest concerns. Please include all considerations that may help us make the best recommendations for your pet.*
COMMERCIAL DIETS:
Do you offer your pet commercially available diet(s) (either alone or in conjunction with other/homemade diet(s)? (Note: Just*

Yes, I feed ONLY commercial diet(s) right nowYes, I feed commercial diet(s) in conjunction with other/homemade diet(s)No, I do not feed commercial diet(s)No, I do not feed commercial diet(s) but would be interested in learning more about themI ONLY feed fresh food company diets (incl. Just Food For Dogs or The Farmer's Dog; diets with fresh ingredients, available commercially in stores/online)I feed fresh food company diets (incl. Just Food For Dogs or The Farmer's Dog; diets with fresh ingredients, available commercially in stores/online) in conjunction with other/homemade diet(s)I feed fresh food company diets (incl. Just Food For Dogs or The Farmer's Dog; diets with fresh ingredients, available commercially in stores/online) conjunction with other commercial diet(s)

Brand --------------------	Specific Name (Species, flavor, etc.) --------------------	Form (dry, canned, stew) -------------------	Amount per meal (8 oz. cups vs. #oz. can) -------------------	Meals per day -------------------	Total Per Day -------------------
Daisy's Dog Food	Canine, Renal Support A	dry	¼ cup of an 8 oz. cup	3	¾ cup per day

Please list your pet's current commercial diets*

	Brand	Specific Name (Species, flavor, etc.)	Form (dry, canned, stew)	Amount per meal (8 oz. cups vs. #oz. can)	Meals Per Day	Total Per Day
1
2
3
4
5

Please only list current commercial diets (not past diets)*

	Brand	Specific Name (Species, flavor, etc.)	Form (dry, canned, stew)	Amount per meal (8 oz. cups vs. #oz. can)	Meals per day	Total Per Day
1
2
3
4
5

Please list additional pertinent history regarding your pet and commercial diets. For example, are there previous commercial diets that your pet did poorly on? (Please write N/A if no answer):*
Homemade diets: If you offer a homemade diet please write your recipe in as much detail as possible. You can also upload PDFs or word docs:
Homemade recipe documents (if applicable)

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TREATS:

To the best of your ability, please list all current commercial OR human-food treats fed to your pet. Please see the example before proceeding. (Please write N/A in Brand row 1 if you do not give any treats):

Brand ------------------------------	Specific Name(Species, flavor, etc.) ------------------------------	Amount Per Day ------------------------------	Size -----------------------------
Freddie's Choice Cat Treats	Feline, Original Flavor	2	Large

Please only list current treats (not past treats)*

	Brand	Specific Name (Species, flavor, etc.)	Amount Per Day	Size
1
2
3
4
5
6
7
8
9

Please review the above information. Please use this box to describe any food, human foods, or treats given (either routinely or occasionally) to your pet that have not been listed already (Please write N/A if no answer):*
SUPPLEMENTS

To the best of your ability, please list all supplements (prescription and over-the counter) given (or recently given) to your pet. Please see the example before proceeding (Please write N/A in Brand row 1 if you do not give any Supplements):

Brand ----------------	Flavor, Name (if applicable) ----------------	Active Ingredient ----------------	Concentration per capsule ----------------	Amount per day ----------------	Did a vet prescribe? (Yes/No) ----------------	Current or past? ----------------
Scramble's Supplements	1400mg Fish Oil (no flavor)	Omega-3 Fatty Acids (EPA +DHA)	1400mg Fish Oil (980mg EPA + DHA)	2	Yes	Current

Please only list current supplements (not past supps)*

	Brand	Flavor, Name (if applicable)	Active Ingredient	Concentration per capsule	Amount per day	Did a vet prescribe? (Yes/No)
1
2
3
4
5
6
7
8
9

MEDICATIONS:

To the best of your ability, please list all medications (prescription and over-the-counter)given (or recently given) to your pet. Please see the example before proceeding. (Please write N/A in Brand row 1 if you do not give any Meds):

Brand ----------------	Flavor, Name (if applicable) ----------------	Active Ingredient ----------------	Concentration per capsule ----------------	Amount per day ----------------	Did a vet prescribe? (Yes/No) ----------------	Current or past? ----------------
Prilosec	N/A	Omeprazole	20 mg	1	Yes	current

Please only list current medications (not past meds)*

	Brand	Flavor, Name (if applicable)	Active ingredient	Concentration per capsule	Amount per day	Did a vet prescribe? (Yes/No)
1
2
3
4
5
6
7
8
9

If you have additional Supplements/Medications currently fed, please continue below (include the same information as in the table). (Please write N/A if no answer):*
Has your pet been on any diets/treats/supplements or meds previously that they DID NOT respond well to? (Please write N/A if no answer)*
DO NOT FEED

Artificial sugars (especially xylitol aka birch sugar/sap), onions, garlic, raisins, grapes, tamarinds, chocolate (or cocoa), macadamia nuts, avocado, bones, large pieces of fruits/vegetables (that may cause choking) or raw meat**/eggs

**Raw Diet note: We do not recommend feeding a raw diet due to the health risks to both pets and their humans living in the home. We are happy to talk more about this in your appointment.
INDIVIDUAL INGREDIENTS/Homemade Diets
If you would like to provide or you feel we would benefit from knowing specifc ingredient information (for example, if you are interested in a homemade diet for your pet), please fill out the following so our doctors can get a better sense of preferences in your home.

You do not have to fill each box.

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Homemade Diets: We are happy to create homemade diet plans for our patients! Although it is common to cook for ourselves, creating balanced, healthy meals for our pets is a different challenge, even more so if you have a pet with special health needs. Did you know that a study examined pet recipes found online and 95% had at least one deficiency of an essential nutrient? Some of these recipes were from reputable sources and in some cases, even other veterinarians. Nutritional deficiencies and excesses may not show obvious clinical signs for months or even years, but can prevent our pets from being in their best health. Therefore, it is strongly recommended to establish a relationship with a veterinary nutritionist if you wish to home cook for your pet. Our Clinical Nutrition team reviews patient records, meets with owners to discuss their pet’s needs, and creates recipes based on health needs and owner/patient preferences. All recipes will be examined for 40+ nutritional components to ensure it meets our recommendations and avoid deficiencies/excesses.

Commonly used meats (Please "X" to denote your choice per ingredient) pt. 1:

	Pet Likes	Pet Dislikes	Pet is Indifferent	Owner Would rather NOT use	Pet is Sensitive/Allergic	Unsure
Chicken, white meat
Chicken, dark meat
Ground turkey
Pork tenderloin, trimmed
Ground beef, 92-97% lean
Eggs, boiled or cooked
Egg whites, pasteurized or cooked
Tilapia
Cod

Commonly used carbohydrates (Please "X" to denote your choice per ingredient) pt. 2:

	Pet Likes	Pet Dislikes	Pet is Indifferent	Owner Would rather NOT use	Pet is Sensitive/Allergic	Unsure
Rice, white
Rice, brown
Sweet potatoes
White and/or yellow potatoes
Quinoa
Oatmeal
Pasta

Commonly used fruits and vegetables (Please "X" to denote your choice per ingredient) pt. 3:

	Pet Likes	Pet Dislikes	Pet is Indifferent	Would rather NOT use	Pet is Sensitive/Allergic	Unsure
Carrots
Peas
Lima beans
Green beans
Canned pumpkin
Corn
Broccoli
Cauliflower

Commonly used fruits and vegetables (Please "X" to denote your choice per ingredient) pt. 4:

	Pet Likes	Pet Dislikes	Pet is Indifferent	Owner Would rather NOT use	Pet is Sensitive/Allergic	Unsure
Zucchini
Yellow squash
Bell peppers
Apples
Bananas
Blueberries
Strawberries
Melon (cantaloupe, watermelon)

Less common ingredients that can also be tried include (not an exhaustive list; please "X" to denote your choice per ingredient):

	Pet Likes	Pet Dislikes	Pet is Indifferent	Owner Would rather NOT use	Pet is Sensitive/Allergic	Unsure
Ground chicken
Salmon
Shrimp
Lamb
Bison
Other poultry (pheasant, quail)
Tofu
Venison
Barley
Bread
Bulgur
Button or shitake mushrooms
Chickpeas
Pinto beans
Rice cereal (for infants)
Tomatoes
Wild rice

If you have any other notes about individual ingredients or any information you think it would benefit us to know, please write it here (If you feed a homemade diet you may also use this space to detail ingredients and measurements). (Please write N/A if no answer):*

ADDITIONAL QUESTIONS
If not already described, does your pet has any known dietary sensitivities? What type of response/symptoms does your pet experience (ex: Skin, Gastrointestinal, etc.)? (Please write N/A if no answer)*
Please list any foods (human or pet) your pet WILL NOT consume. (Please write N/A if no answer):*
Please provide any additional information you would like us to know about your pet’s eating habits or your diet philosophy (ex. religious, cultural limitations, owner medical concerns). (Please write N/A if no answer):*
Who typically feeds your pet (you, spouse, child, other caretaker, etc.)? Are there any family members etc. in the house that give your pet additional food and table scraps? If so, please specify what is given and how much/ how often? *
Are there any other pets in the house? Does this pet (i.e., our patient) have access to the other pet’s food? If so, please specify what food your other pet is fed (if different)? *
EXERCISE HISTORY: How much exercise does your pet get per day? (distance, duration, frequency. Ex: 2-mile walk, ~ 45 minutes, twice daily)? Are there stairs in your house? Is your pet able to go up and down without help? *
Medical Records: As part of the intake process we need complete records. Please reach out to your vet to have them email nutrition@friendshiphospital.com full records and labs. If you have additional records, please also send those to the above email. (Please check below to confirm you have read and understood that the appointment cannot move forward without medical records/labs):

I will reach out to all of the vets currently seeing my pet to send records/labs to nutrition@friendshiphospital.com and to notify them a Vet Referral form will be coming to them for the clinic to fill out.
Upload Medical Record (if you have them; if not, we automatically reach out to your vet for full records)

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Upload Images of Pet. Our preference is 3 photos: 1) face picture 2) 'airplane' body picture when pet is standing, and 3) lateral body picture when pet is standing. See here for an example: https://wsava.org/wp-content/uploads/2020/01/Body-Condition-Score-Dog.pdf*

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If you don't have a pic to upload at the time you're filling out the form, just upload a stock photo from your devise and send the requested images of your pet separately.

Please feel free to send image attachments for the food, treats, and/or supplements to nutrition@friendshiphospital.com (just make sure to denote your name and pet's name so we know who to attribute your email to).

Additional information is always welcome!

SCHEDULING
Consult Type*
Please confirm which phone number we should use for your consult (please type your number as ###-###-####).

Please select days that you are usually available. We will reach out with a tentative date and time of appointment but can work with you if that date/time doesn't work.*

	Monday	Tuesday	Wednesday	Thursday	Friday
AM
PM

Any other scheduling notes you would like to add?

WHAT TO EXPECT & PRICING
Downloadable copy of "What To Expect" (Click the down arrow or print option)
If you don't have a pic to upload at the time you're filling out the form, just upload a stock photo from your devise and send the requested images of your pet separately.

Please feel free to send image attachments for the food, treats, and/or supplements to nutrition@friendshiphospital.com (just make sure to denote your name and pet's name so we know who to attribute your email to).

Additional information is always welcome!

CLIENT EXPECTATIONS
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Please read and check each statement and sign (type) your signature and date at the bottom of this form.
I, (the client) understand that:*

The recommendations and personalized treatment plan (if applicable) provided by my FHA nutritionist are created using a) the information provided above and b) all available/ provided medical records. It is the responsibility of the client to inform the FHA Nutrition Service if the patient/pet is being treated by multiple veterinary practices.I understand that I will be provided with the estimated turnaround time, discussed with me during my pet’s appointment. Due to the considerable research that goes into each plan’s production, final turnaround time may be longer than estimated, but we work to get you your plan as quickly as possible.I will contact the FHA Nutrition Service in a timely manner if there is any question or concern that my pet is not tolerating the dietary plan and recommendations. If you have not received your notes/plan in a timely manner it is your responsibility to reach out for an update.I agree to, and understand, the fees associated with my pet’s services and agree to pay for services rendered in a timely manner.FULL Payment is due at time of service for all services including homemade diets and commercial recommendations, and MUST be received prior to the making and sending out of plans.PLEASE NOTE: I understand that communication will be by email via nutrition@friendshiphospital.com. Although we make every effort to respond to emails quickly, please allow 3-5 business days for a response. We recommend directing emergency questions to your regular veterinarian.
Signature (Please type full name)*
By typing your full name, you signing are confirming you read and understand the Client Expectations including pricing and Deposit requirements.
Date of Signature*

MonthDayYear
Should be Empty:

FHA Diet History/ Questionnaire

COMMERCIAL DIETS:

TREATS:

SUPPLEMENTS

MEDICATIONS:

INDIVIDUAL INGREDIENTS/Homemade Diets

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