Nutrition Patient History Form

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Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Pet Information

Pet's Name*

Species*

Dog

Cat

Date of birth*

Breed*

Color*

Gender*

Male

Female

Spayed/Neutered/Intact*

Spayed/Neutered

Intact

Bodyweight*

Unit*

Date bodyweight measured*

Referring Veterinarian Information

Veterinarian Name*

First Last

Clinic Name*

Phone*

Email

Have you notified your veterinarian about contacting us?*

Yes

No

Do we have permission to contact your veterinarian?*

Yes

No

Has your pet received medical attention for the current issue from a veterinarian other than your primary one?*

Yes

No

Veterinary Clinic Name*

Please provide the name of the veterinary clinic from which your pet received medical attention for the current issue.

Email*

Phone*

Pet's Diet History

Please list what your pet is currently being fed, and diets you have fed to your pet in the past.

Example for commercial diet: Purina Pro Plan dry food, Sensitive Skin and Stomach Salmon, 1 cup, Twice daily, Fed since May 2015.
Example for home-prepared diet: Ground beef (80% lean, 20% fat), Pan-browned in 1 tablespoon olive oil, 1 cup cooked, Twice daily, January 2014-October 2016.

Click the plus icon (+) on the right to add a row.

Current Diet History*

Brand of commercial food, or ingredients of home-prepared diet

Flavor

Amount fed per meal

Times fed per day

Fed since

Previous Diet History (no longer being fed)

Brand of commercial food, or ingredients of home-prepared diet

Flavor

Amount fed per meal

Times fed per day

Fed since

Treats: Commercial, Human Food or Home Prepared (current and previously given treats)

Example: Biscuit, Old Mother Hubbard, Classic Liv’R’Crunch oven-baked dog biscuits, Mini, 6, Still feeding.

Treat type

Brand

Flavor

Size

Number fed per day

Reason stopped

Are you interested in commercial diet recommendations?*

Yes

No

Are you interested in a homemade diet formulation?*

Yes

No

Disclaimer

Preparing food for your pet requires additional time and expense. Some dogs and cats will not eat a home-prepared diet. Prior to the consultation, you may want to try introducing small amounts of food items you would like to include in the diet to assess your pet’s willingness to eat them. Diets are formulated using computer software to meet dietary needs according to the NRC or AAFCO, unless modified for medical reasons. If you would still like to move forward with the creation of a home-prepared diet at this time, select the checkbox below.

Protein Ingredients

Please select protein ingredients your pet has consumed in the past or is currently eating. Please also indicate if there are any ingredients you would prefer to use or avoid using in a homemade diet. NOTE: Not all ingredients may be appropriate for the pet. In some cases, additional ingredients not listed may be suggested.

Protein Ingredients

	Consumed in the past	Currently eating	Prefer to use	Prefer to avoid
Chicken
Liver
Turkey
Beef
Lamb
Duck
Rabbit
Venison
Kangaroo
Bison
Salmon
Tilapia
Tuna
Other fish (specify in the comments below)
Shrimp
Chicken egg
Cheese (specify type in the comments below)
Cottage cheese
Soybean/Tofu
Yogurt
Peanut butter
Cream cheese
Chickpeas
Pinto beans

Carbohydrate Ingredients

Please select carbohydrate ingredients your pet has consumed in the past or is currently eating. Please also indicate if there are any ingredients you would prefer to use or avoid using in a homemade diet. NOTE: Not all ingredients may be appropriate for the pet. In some cases, additional ingredients not listed may be suggested.

Carbohydrate Ingredients

	Consumed in the past	Currently eating	Prefer to use	Prefer to avoid
White rice
Brown rice
Barley
Oats/Oatmeal
Wheat pasta
Other pasta (specify in the comments below)
White potato
Sweet potato
Lentils
Millet
Quinoa
Wheat berries
Green split peas
Mung beans
Tapioca
Polenta (ground corn)
Green beans
Carrots
Corn
Spinach
Green peas
Broccoli
Cauliflower
Zucchini
Squash (specify type in the comments below)

Additional comments

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Owner Information

Pet Information

Referring Veterinarian Information

Pet's Medical History and/or Concerns

Information: Additional Pets in the Household

Pet Lifestyle Information

Pet's Diet History

Disclaimer

Protein Ingredients

Carbohydrate Ingredients