CLINICAL ANIMAL NUTRITION SURVEY FORM

CLINICAL ANIMAL NUTRITION SURVEY FORM

A System Approach to Identifying Vitamin and Mineral Imbalances and Organ Distress. Restricted to Professional Veterinary Use.
Kindly note that this form is only meant for Dr. Ava Frick HTMA Test.

CAUTION : THIS FORM MIGHT BE BEST VIEWED ON LANDSCAPE FORMAT.

Your intake survey is an important part of Dr. Ava Frick's ability to get your pet the most calibrated wellness reporting possible. As your pet's best friend, you know them best. We ask that you carefully and accurately answer each question. If you are unsure of which to select, choose the option closest to the signs exhibited by your pet.
Today's Date*

DayMonthYear
Order Number*
Order number can be found after you have completed the purchase on our website.
Pet Type*
Owner's Name*
Owner's Email*
Pet Name*
Pet Weight*
Input in kg
Pet Age*

In all the tables below, put a number in the box in front of the symptom that only applies to your animal.

LEAVE BLANK if it does not apply.

Input "1" ---> if symptom is mild or not very often.

Input "2" ---> if symptom is moderate or somewhat frequent.

Input "3" ---> if symptom is severe or constantly happening.

Dog Page 1

GROUP ONE - SYMPATHETIC - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Dry mouth, eyes, nose
Vomits with excitement
Isolates away from family or pets
Keyed up, fails to calm
Tends toward aggression
Afraid of storms, fireworks
Nervous
Fear biter
Doesn’t adapt easily to routine change
Unable to relax, startles easily
High anxiety
Obsessive compulsive behavior

GROUP TWO - PARASYMPATHETIC - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Joint stiffness with rising
Subject to infections
Poor circulation, sensitive to cold
Always seems hungry
Eyes or nose watery
Moist body, often an odor
Couch potato-like attitude
Eats dirt
Sleeps more than used to
Slow starter, slow mover
Constipation, diarrhea, alternating
Little interest in anything

GROUP THREE – CARBOHYDRATE METABOLISM, SUGAR HANDLING - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Trembles, episodes of weakness
Urinating large amounts
Weight loss
Seizures
Hungry often, eats fast
Behavior changes
Disoriented at times
Change in appearance of eyes
Increased water consumption
Increased sleep, decreased activity
Cannot lose weight even with diet
Overweight
Wheat, corn, rice, barley, oats in diet
Eats feces
Passes gas

GROUP FOUR – CARDIO RESPIRATORY, CIRCULATION - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Exercise intolerance
Cough, especially at rest
Swelling in rear legs
Significant loss of muscle mass
Seems disoriented at times
Difficulty breathing
Fainting, collapse
Rear legs tremble, weak
Shortness of breath
History of heartworms
Enlarged heart
Has had pneumonia more than once

GROUP FIVE – HEPATIC, GALL BLADDER - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
On meds over long time
Allergies
Stands with back arched
Stool watery or diarrhea
Seizures, tremors
Elevated cholesterol, triglycerides
Appears bloated
Change in appetite
Elevated liver enzymes, lipase
Restless, can’t get comfortable
Frequent anesthetics
Gas, indigestion
Increased shedding
Food sensitivities
Ocular discharge, red eyes
General itchiness
Anal Sac problems, Scooting
Early morning vomit
Sporadic vomit/diarrhea
Licks or chews at feet or anus
Crusty lip sores

GROUP SIX - DIGESTION - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Vomits after fatty meal
History of pancreatitis
Intermittent vomiting
Halitosis
Recurrent diarrhea
Excessive or chronic eye drainage
Pale-colored stool
Rancid odor to stool
Poor coat
Stomach distress common
Belches, regurgitation
Recent intestinal parasites

Dog Page 2

GROUP SEVEN – A – THYROID GLANDS - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Increased shedding
Oily, greasy coat, body odor
Depression, mentally dull
Thinning, sparse coat, bald spots
Weak pulse
Exercise intolerant
Warts
Elevated blood cholesterol
Back/neck problems
Dry, scaly skin
Fatty tumors
Increased pigment to skin
Obese or can’t lose weight
Stiff gait
Weak knee ligaments

GROUP SEVEN – B – PITUITARY GLANDS - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Failing memory
Weight gain around rear end, fat pads
Abnormal heat cycles of intact females
Abnormal thirst
Neutered male retains sexual activity
Pigment spots to skin

GROUP SEVEN – C – ADRENAL GLANDS, HYPERACTIVE - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Excessive water consumption
Panting more than used to
Increased appetite
Increased urination
Lethargic
Distended abdomen
Thin skin
Pacing
Change in behavior
Decline in arthritic symptoms
Weak knees, weak muscles
Thinning fur

GROUP SEVEN – D – ADRENAL GLANDS, HYPOACTIVE - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Weakness
Slow heart
Intermittent anorexia
Depression
Weak pulse
Collapse

GROUP EIGHT – MUSCULOSKELETAL (CALCIUM / MAGNESIUM METABOLISM) - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Older dog
Difficulty getting up and down
Losing muscle tone in legs or back
History of any joint surgery
Arthritic, degenerative joint disease
Healing fracture in body
Back or disc problems
Has had ligaments damaged
Suffering from a sprain or strain
Bone spurs or enlarged joints
Rapidly accumulates tarter on teeth
Difficulty supporting weight

GROUP NINE - RENAL - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Abnormal or frequent urination
History of bladder stones
Leaking urine
History of bladder infections
Licking at penis or vulva
Wants to go outside more often
Reduced renal function
Cries when urinating
Prostate enlarged
High blood calcium &/or phosphorus
Elevated vitamin D
14 or more years old

GROUP TEN – IMMUNE - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Increased shedding
Eye infection
Frequent infections
Red bumps to skin
Treated for parasites
Odor that returns shortly after bath
Scabs, sores, or crusts to skin
Body or ear odor
Moist or heat under front/rear legs
Dandruff, flaking
Ear infection
Enlarged lymph nodes
Has had cancer
Experienced a vaccine reaction
Dental infection

GROUP ELEVEN – PAIN - DOG

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Lameness, abnormal gait
Playing less
Wobbly
Withdrawn, hiding
Less interested in going for a walk
Shifting weight off area of body
Reluctant to move
Change in mood, grumpy
Licking excessively an area of the body
Dislike or intolerance of handling
Hunched back or sway back
Restlessness; pacing
Overall activity less than normal
Groaning, moaning, grunting
Lower or tilted head or ears
Looks depressed
Weeping, red, cloudy or squinting eyes
Temperamental, yelp or growl at others
Hanging or tucked tail
Heavy panting, increased heart rate
Change in toileting habits
Decreased appetite
Change in appetite & type of food willing to eat
Recent surgery, dental infection
Licking inanimate objects (can often be a sign of intestinal pain)

Dog Page 3
IMPORTANT!
Please list below the five main physical and or health complaints for this dog in order of importance:

1 BEING THE MOST IMPORTANT, 5 BEING THE LEAST.
1.
0/80
2.
0/80
3.
0/80
4.
0/80
5.
0/80
Other comments regarding your dog you would like to add?

(eg, health history etc... anything you would like to highlight to Dr. Ava Frick)0/400

Cat Page 1

GROUP ONE - SYMPATHETIC - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Dry mouth, eyes, nose
Vomits with excitement
Skin sores, lesions
Keyed up, unable to relax
Tends toward aggression or anxiety
Vomits, nervous stomach
Fur loss on tail, legs, tummy
Hides a lot
Sheds a lot, especially when excited
Excessive grooming
Prowls day and night
Obsessive compulsive behavior

GROUP TWO - PARASYMPATHETIC - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Joint stiffness with rising
Subject to infections
Poor circulation, sensitive to cold
Always seems hungry
Eyes or nose watery
Constipation, diarrhea, alternating
Lazy, Slow starter, slow mover
Overweight
Sleeps more than used to

GROUP THREE – CARBOHYDRATE METABOLISM, SUGAR HANDLING - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Trembles, episodes of weakness
Large amount of urine in box
Belly distended but thin along back
Seizures
Hungry often, eats fast
Behavior changes
Disoriented at times
Change in appearance of eyes
Drinks a lot of water, sits at bowl
Difficulty walking straight
Weight loss
Overweight
Wheat, corn, rice, barley, oats in diet
Walks low in rear
Body sagging in middle

GROUP FOUR - CIRCULATION - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Exercise intolerance, lethargy
Coughing
Weak in rear legs
Significant loss of muscle mass
Seems disoriented at times
Difficulty breathing. Wheezing
Short rapid breathing, open mouth
Vomiting
Cold rear legs
Weight loss
Enlarged heart
Poor appetite

GROUP FIVE – HEPATIC, GALL BLADDER - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
On meds over long time
Subject to allergies
Stands with back arched
Stool watery or diarrhea
Seizures, tremors
Elevated cholesterol, triglycerides
Appears bloated
Change in appetite
Elevated liver enzymes, lipase
Obese
Food sensitivities
Ocular discharge
Recent or rapid weight loss
Anal Sac problems, Scooting
Rubs at ears or face
Sporadic vomit/diarrhea
Recent stressful event
Increased salivation
Lethargic
Green / dark stool
Restless

GROUP SIX - DIGESTION - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Picky eater or episodes or anorexia
History of pancreatitis
Intermittent vomiting
Halitosis
Recurrent diarrhea
Excessive or chronic eye drainage
Subject to allergies
Sores in mouth or on lips
Poor coat, sheds a lot
Sensitive stomach
Vomits fur balls
Recent intestinal parasites

Cat Page 2

GROUP SEVEN – A – ENDOCRINE - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
More than 10 years old
Stiff gait Oily, greasy coat
Drinking a lot, increased urination
Weight loss
Nervous
Fast heart rate or pounding chest
Warts
Aggressiveness
Back/neck problems
Dry, scaly skin
Spastic movements, restless
Up all night, can’t sleep
Hungry all the time
Diarrhea or vomiting
Looks for cool places to rest

GROUP EIGHT – MUSCULOSKELETAL (CALCIUM / MAGNESIUM METABOLISM) - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Senior cat
Difficulty getting up and down
Losing muscle tone in legs or back
History of any joint surgery
Arthritic, degenerative joint disease
Stopped or reduced jumping
Back or disc problems
Back problems, stiffness
Walks low to the ground
Weak joints, poor muscles
Dental tartar or cavity
Difficulty getting into litter box

GROUP NINE - RENAL - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Abnormal or frequent urination
History of bladder stones, crystals
Drinking more water
History of bladder infections
Licking at penis or vulva
Urinates outside litter box
Reduced renal function
Cries when urinating
In and out of litter box
High blood calcium or phosphorus
Can’t get comfortable
Diet mostly dry food

GROUP TEN – IMMUNE - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Sheds, poor fur quality, dandruff
Runny eyes
Frequent infections
Red bumps to skin
Recurrent sneezing
Dental infection
Scabs, sores, crusts to skin or mouth
Ear infections, lesions
Has had cancer
Frequently on antibiotics
Has FELV, FIV, AIDS, or Toxoplasmosis
Experienced a vaccine reaction
Gets infections easily
Is over 12 years old
Lives with 4 or more cats

GROUP ELEVEN – PAIN - CAT

	1 = mild or not very often	2 = moderate or somewhat frequent	3 = severe or constantly happening.
Lameness, abnormal gait
Recent surgery, dental infection
Weeping, red, cloudy or squinting eyes
Withdrawn, hiding
Flicking tail
Shifting weight off area of body
Reluctant to move
Change in mood, grumpy
Licking excessively an area of the body
Dislike or intolerance of handling
Hunched back or sway back
Temperamental, growl at others
Overall activity less than normal
Groaning, moaning, grunting
Change in toileting habits
Looks depressed
Change in appetite & type of food willing to eat

Cat Page 3
IMPORTANT!
Please list below the five main physical and or health complaints for this cat in order of importance:

1 BEING THE MOST IMPORTANT, 5 BEING THE LEAST.
1.
0/80
2.
0/80
3.
0/80
4.
0/80
5.
0/80
Other comments regarding your cat you would like to add?

(eg, health history etc... anything you would like to highlight to Dr. Ava Frick)0/400
Should be Empty: