Nutrition Consultation- Pet Owner Provided History
This form is to be filled out prior to a nutrition consultation with Dr Mady. Please DO NOT fill out this form if you are not an active client with Little Creek Veterinary Clinic. Please call us or fill out our new client form first to establish your file.
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.
Email
*
example@example.com
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: