Nutrition Consultation- Pet Owner Provided History
This form is to be filled out prior to a nutrition consultation with Dr Mady.
Owner and pet information
Owner
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Pet Name
*
Birthdate
-
Month
-
Day
Year
Date
Age if Birthdate unknown
*
Species (Canine or Feline)
*
Sex (Male, Male Neutered, Female, Female Spayed)
*
Current Diet and Eating Habits
Current Diet, Brand of commercial food:
*
Type of food
*
Please Select
Dry Kibble
Canned
Raw
Freeze Dried
Homemade
Other
If other, please state below:
Flavor or variety:
*
Portion size (cups/grams per meal):
*
Feeding frequency (meals per day):
*
What does your pet like to eat?
*
What doesn't your pet like to eat?
*
Has your pet ever had any adverse food reactions?
*
Yes
No
If yes, please describe what occurred::
*
Please write n/a if no adverse reactions.
Feeding Method:
*
Please Select
Portion controlled (specific measured amounts per meal)
Time-restricted (fed at specific times of day)
Free feeding (food is constantly available)
How is your pet food stored at home?
*
Does your pet have a good appetite?
*
Have you noted any difficulties when your pet eats? If yes, please describe:
*
Tell us about any recent changes in anything your pet eats:
*
Any additional comments?
*
Please write n/a if no additional comments.
Treats and Medications:
Tell us about the treats your pet receives:
*
Does your pet receive any medications or supplements?
*
Supplements
Medications
None
Please list any supplements or medications your pet received along with the frequency and dose of each:
*
Is the pet experiencing any vomiting or diarrhea?
*
Yes
No
If yes, how frequently is the pet experiencing these symptoms?
*
Daily
Weekly
Monthly
When certain foods are given
Other
Not applicable
Pets Activity Level
Describe your pets typical daily activity level (e.g. sedentary, moderately active, highly active):
*
Have you noticed any recent changes in activity level?
*
Weight Changes
Have you noticed any weigh loss or weight gain?
*
Weight Loss
Weight Gain
Neither
What is the percentage of change in weight?
*
What is the time frame of the change?
*
Please Select
1-2 weeks
1 month
2-3 months
6 months
1 year
>1 year
Body condition score (if known)
*
Ideal
Underweight
Overweight
Unsure
Please provide your assessment of the pet's body condition:
*
Muscle Condition
Is the pet losing muscle mass?
*
Yes
No
Not sure
Do you monitor your pets muscle condition?
*
Yes
No
Hydration
Does the pet have good hydration?
*
Is water available at all times?
*
Yes
No
How is water offered?
*
Bowl
Fountain
Other
If other, please describe:
Do you think your pet is excessively drinking?
*
Yes
No
Do you feel like your pet should be drinking more?
*
Yes
No
Home Environment
Tell us about where your pet spends his/her days and nights:
*
What people live with your pet? Are they involved in the feeding routine?
*
Sleep and Toileting Habits
Tell us about your pets sleeping habits:
*
Tell us about your pets toileting habits:
*
Additional information/Goals
Do you have any additional information you would like to provide us?
What are your nutrition goals and expectations going forward?
*
Submit
Should be Empty: