Nutrition Consultations
This form is to be filled out prior to a nutrition consultation at Airdrie Animal Hospital.
Owner Information
Owner
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Patient Information
Pet's Name
*
Species
*
Please Select
Canine
Feline
Birthdate
-
Month
-
Day
Year
If the exact date is unknown, please provide an approximate age
Age
Gender
*
Please Select
Male
Male, Neutered
Female
Female, Spayed
What are your nutrition goals and expectations for your pet?
*
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Patient History and Lifestyle Questions:
Please answer the following questions with as much detail as possible.
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Diet and Eating Habits
Current brand, diet and flavour of pet food:
*
Please provide the brand and full name of the diet.
Type(s) of food:
*
Kibble
Wet/ Canned
Raw
Freeze Dried
Homemade
Other
Portion size (cups/grams per meal):
*
Feeding frequency (meals per day):
*
Feeding method(s):
*
Portion controlled (specific measured amounts pet meal)
Time-restricted (fed at specific times of the day)
Free fed (food is constantly available)
How do you store your pet's food at home?
*
Does your pet have a good appetite?
*
Yes
No
Sometimes
Have you noted any difficulties when your pet eats?
*
Yes
No
Please describe the difficulties they've experienced:
*
Is your pet experiencing any vomiting or diarrhea?
*
Yes
No
How often is your pet experiencing these symptoms?
*
Daily
Weekly
Montly
After consuming certain foods
Other
Has your pet ever had an adverse or allergic reaction to food?
*
Yes
No
I'm not sure
Please describe what happened:
*
What foods does you pet like to eat?
What foods does you pet NOT like to eat?
Tell us about any treats or human foods your pet receives, how much, and how often:
*
Please provide as much detail as possible; including treat brands and flavours.
Additional comments:
Let us know if there have been any recent changes to your pet's diet, eating habits or anything else you think we should know.
Drinking Habits
Is water available to your pet at all times?
*
Yes
No
Do you think your pet is drinking...
*
Excessivley
Not Enough
Normally
I don't know
How is water offered?
*
Please Select
Bowl
Fountain
Other
If other, please described:
Medications and Supplements
Does your pet receive any medications or supplements (including parasite prevention)?
*
Yes
No
List all medications and/or supplements:
*
Please include frequency and dosage.
Activity Level
Describe your pets typical daily activity level:
*
e.g. lethargic, sedentary, moderately active, highly active
Have you noticed any recent changes in your pet's activity level?
*
Yes
No
Please explain the changes you've noticed:
*
Weight and Body Condition
Body Condition Score
*
Please Select
Ideal
Underweight
Overweight
I don't know
Have you noticed any recent changes in your pet's weight?
*
No
Yes, weight loss
Yes, weight gain
What is the time frame of the weight change
*
Please Select
1-2 weeks
1 month
2-3 months
6 months
1 year
> 1 year
Have you noticed your pet losing muscle mass?
*
No
Yes
I don't know
Please explain the changes you've noticed:
*
Routines and Home Environment
Tell us what your pet's typical day looks like:
*
Where does your pet spend most of their time? What people live with your pet and are they involved in the feeding routine?
Tell us about your pet's sleeping habits:
*
Tell us about your pet's toileting habits:
*
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Anything else?
Is there anything additional you would like us to know/?
Submit
Should be Empty: