Pet Owner Diet History Questionnaire

Pet Owner Diet History/ Questionnaire

COMMERCIAL DIETS:

TREATS:

MEDICATIONS AND SUPPLEMENTS:

Last section, we promise!

Pet Owner Diet History/ Questionnaire
To schedule an appointment:

1) Please fill out this form. Please allow 20-30 minutes. If you need to save it and finish later, scroll to the very bottom of the page. Once complete, a copy will be sent to your email.

2) Ask your vet(s) to fill out a referral form and email records.

3) We will reach out to you for deposit information and to schedule. Average wait times are 1-2 months. Kindly note that pre-payment for an initial appointment will be required in order to schedule.

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Current Pricing:

New client appointment: $549

Recheck appointment: $366 per hour

Additional services: $200-460+

While we try to advise as much as possible during an appointment, please note that services such as tailored/long-term homemade diets, etc. are an additional charge. Please see website for more information. Prices subject to change

Common example: a tailored homemade diet is $549 (appointment) + $326 (recipe)= $875

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PLEASE NOTE:
- We operate on a referral basis. Your veterinarian must complete out a referral form and send medical records prior to establishment with our service.
- We are virtual only. All appointments are via video or phone.
- Wait times can be 1-2 months for appointments. You can be on a cancellation list, if desired, for spots that may open up sooner.
- A deposit of the appointment fee ($549) will be required to hold your appointment spot. This is transferrable if the appointment is rescheduled or refundable (minus a $50 processing fee) if the appointment is cancelled with at least 48 hours notice.
- We love to educate and partner with certain veterinary groups and universities. There may be a rotating intern/student/resident/technician participating in your appointment. All nutrition plans are made/finalized by the nutritionist.
- Software including AI and recordings may be used to help optimize your pet's care.
- Your veterinarian will be copied on pertinent information including appointment notes and nutrition plans.
- Please email us at nutrition@peakveterinaryspecialists.com if you have any questions!
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Owner 1 (required)

PrefixFirst NameLast Name
Owner 2 (if more than one owner)

First NameLast Name (this is especially important if you have records under a different last name at other clinics)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 1 (please double check your email address as this is our primary form of communication)
example@example.com
Email 2 (This is the 2nd email address that will receive all communication, appointment invites, and reports)
example@example.com
How did you find us?

Pet Name
How is your pet's name pronounced?
Canine/Feline?
My animal is:
Breed
Pet Gender/Neuter Status
Coat Color
Age
Birthdate (if known)

MonthDayYear

Hospital/Clinic Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor (if known)
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.Format: (000) 000-0000.
INTERNATIONAL CLINICS: Clinic Phone number (with country code)
Please do NOT just enter which country you're in, thanks!
Does your pet see any of these hospitals for any services, primary or specialty?
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):

DESIRED SERVICES (choose all that apply)
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.
Many of our patients have complicated health needs and may not have a local internal medicine specialist option. Therefore, we are excited to announce that Dr. Mui (DVM, DACVIM- IM) will be providing internal medicine consults to established Nutrition clients. These are written consultations based on record review and do not include direct communication with Dr. Mui. The additional fee is $253. If desired, this can be discussed further with your Nutritionist.
COMMERCIAL DIETS:
What kind of diet do you feed right now: Do you offer your pet commercially available diet(s) (either alone or in conjunction with other/homemade 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 -------------------
Example Dog Food	Canine, Example Type A	dry	¼ cup of an 8 oz. cup	3	¾ cup per day

Please list your pet's current commercial diets (Please write N/A in one of the boxes if no answer):

Please only list current commercial diets (not past diets)

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 write N/A in Brand row 1 if you do not give any treats):

What kind of treats do you feed your pet? Include human food if given as treats.

Rows	Brand	Specific Name (Species, flavor, etc.)	Amount and frequency	Size, if applicable	Calories per treat (if known)
1
2
3
4
5
6
7
8
9

Please review the above information. We want to ensure we have an accurate description of your pet's current diet. 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):
FOODS TO AVOID: Are there previous diets or foods that your pet did poorly on? You can also include any preferences for household or religious considerations. (Please write N/A if no answer):

Please list current supplements

Rows	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 AND SUPPLEMENTS:

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

Please list current medications and supplements

Rows	Medication/Supplement	Concentration	Amount per day	Did a vet prescribe? (Yes/No)
1
2
3
4
5
6
7
8
9

Additional space if needed. Please also feel free to include information on medications/supplements that your pet did NOT do well on. (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)

Commonly used meats (please click on the circle to denote your choice per ingredient):

Rows	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 click on the circle to denote your choice per ingredient):

Rows	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 click on the circle to denote your choice per ingredient):

Rows	Pet Likes	Pet Dislikes	Pet is Indifferent	Owner 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 click on the circle to denote your choice per ingredient):

Rows	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 click on the circle to denote your choice per ingredient):

Rows	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)
Wild rice

If you have any other notes regarding ingredients, please write it here:

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 other foods (human or pet) you would like to avoid and why. This can include any known dietary sensitivities, foods your pet does not like, religious/cultural considerations, etc. Example "I would like to avoid chicken because it causes my dog to have an upset stomach". (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, personal assistant, chef, 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?
COGNITION: If you have any concerns about your pet's cognition or behavior changes, please write them here:
OTHER PETS: 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)?
Many of our patients have complicated health needs and may not have a local internal medicine specialist option. Therefore, we are excited to announce that Dr. Mui (DVM, DACVIM- IM) will be providing internal medicine consults to established Nutrition clients. These are written consultations based on record review and do not include direct communication with Dr. Mui. The additional fee is $253. If desired, this can be discussed further with your Nutritionist.
EXERCISE/PLAY HISTORY: How active is your pet? Details such as walking distance, duration, frequency can be helpful. Are there stairs in your house? Is your pet able to go up and down without help?
Is there any other information you think might be helpful for us to know?
Medical Records: As part of the intake process we need your vet's referral form (sent directly to them) and complete records. Please reach out to your vet to have them email nutrition@friendshiphospital.com full records and labs and to notify them that a referral request will be coming from us. 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):
OPTIONAL: Upload medical record (if you have them; if not, we automatically reach out to your vet for full records)

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OPTIONAL: Upload images of your 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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Doctor Preference
Consult Type
Appointments are via Zoom. If you prefer phone, please note that here:

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

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
AM
PM

Any other scheduling notes you would like to add?
If you are planning on using pet insurance, please list the company and any logistical needs (need for itemized receipts, etc). If you are unsure, you can let us know later.

Last section, we promise!

Please read each statement and sign (type) your signature and date at the bottom of this form.
Please check to signify that you understand the following:

Communication will be primarily by email. Although we make every effort to respond to emails quickly, please allow up to 7 business days for a response. While it is our pleasure to help you and your pets, we are a support service. 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 an email/call back.
Communication and Financial Policies:

Kindly read through so we can ensure clear communication.
1. Communication is primarily by email or recheck appointments. We make every effort to respond to emails quickly, but please allow up to 5 business days for a response. While it is our pleasure to help you and your pets, we are a support service. 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 an email/call back.
  1. Nutrition plans benefit from communication and feedback. If nutritionist input is requested, such as lab work review or plan updates, please schedule a recheck.
  2. We send all plans to you and your referring veterinarian. If you do not receive expected documents/plans via email, please check your spam/junk folder and contact us.
2. PVS is a referral service: The recommendations provided by my PVS veterinarian are created for your pet using a) the information provided above/during an appointment and b) all available/ provided medical records. Please ensure we have any necessary records. PVS operates as a support/referral service and defers any final choices regarding your pet's treatment to their supervising veterinarian.
3. Mutual respect: Both parties will treat each other with mutual respect. I understand that PVS reserves the right to refuse service.
4. Technology: I understand that all appointments are virtual and software including AI or recorded appointments may be used. This will only be used internally to optimize my pet's care and I give consent.
5. Education: We love to educate and partner with certain veterinary groups and universities. There may be a rotating intern/student/resident/technician participating in your appointment. All nutrition plans are made/finalized by the nutritionist. Case information may be shared for educational purposes.
6. Financial: 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 required prior to receiving plans. Homemade recipes and rechecks are charged separately from initial appointments.
7. Cancellation Policy: We understand that schedules can change and strive to be as accommodating as possible. To ensure fairness and availability for all clients, we have the following cancellation policy:
  More than 14 days prior to your appointment:
  You will receive a full refund, minus a $50 administrative/processing fee.
  Within 7-14 days of your appointment:
  You will receive a 50% refund of the appointment fee.
  Within 7 days of your appointment or missed appointments:
  No refund will be issued, but the appointment can be rescheduled.
  
  Please sign below once you have read and agree to the above policies.
Signature (Please type full name)
By typing your full name, you signing are confirming you read and understand the Client Expectations including pricing requirements.
Date of Signature

MonthDayYear
Should be Empty:

Specific Name (Species, flavor, etc.)

Form (dry, canned, stew)

Amount per meal
(8 oz. cups vs. #oz. can)

Meals Per Day

Total Per Day