Online Diet and Nutrition History Form

Pet Name

Current Body Weight

Usual Body Weight

Do you consider your pet:

Over-Weight

Under-Weight

Ideal Weight

Not Sure

Please list below the brand or product names (if applicable) and amounts of ALL foods, snacks, and treats including biscuits, rawhides, pig’s ears, etc. your pet currently eats. This description should provide enough detail that we could go to the store and purchase the food. It should include human foods given as treats or at the table. Please include EVERYTHING your pet eats.

Brand/Product/Flavor, Food Form (dry/can), Amount Per Meal, # of Meals/Day, Fed Since (date): E xamples: 1)Science Diet Adult Lamb Meal & Rice Recipe, dry kibble, 1 cup, twice a day, fed since January 2011. 2)Purina OM, canned food, 1/3 can, three times a day, fed since January 2011. 3)Chicken breast, boiled, 1/2 cup, two times a week, fed since May 2011. 4)Pup-Peroni treats, beef flavored, 1 whole treat at night, fed since February 2009.

Brand/Product/Food Form (dry/can) Amount Per Meal # of Meals/Day Diet Since (date)

Please describe pet’s activity level (i.e. type, duration & frequency):

Do you have other pets? If YES, please list (species, age):

Is your pet fed in the presence of other animals? If YES, please describe:

Does your pet have access to other unmonitored food sources (i.e. food from a neighbor, scavenging from the yard/trash, hunting outdoors, etc.)? If YES, please describe:

Who typically feeds your pet?

How do you store your pet’s food?

Do you use food to administer medication? If YES please describe type of food and amount

Please describe anything you give your pet for dental health (treats, dental chews, bones or similar products)

If you brush your pet’s teeth, please list the toothpaste you use (if any)

Please list other diets your pet has received in the past, indicating the approximate time period when they were fed and the reason the diet was stopped:

Please list the name of each additional supplement your pet receives, indicate how much and how often your pet receives it (i.e. herbal product, fatty acid, vitamin or mineral supplement):

Please list your pet’s current and past medical problems, if any, and whether they have been resolved or not.

Please list all the medications your pet is currently receiving (and dosages, if availble) and any administered over the past three months (indicate medications that are current):

Please check the box, and indicate frequency, if the following problems have been experienced by your pet prior to today’s visit:

Weight Gain

Weight Loss

Vomiting Daily

Vomiting Weekly

Diahrrhea Daily

Diahrrhea Weekly

Have you observed changes in: Urination, Drinking, Defecation, Appetite (list symptoms and time frame)

Does your pet have? ♦ allergies OR difficulty ♦ chewing ♦ swallowing

Do you currently have an appointment scheduled (date/time)? If not, please call us at (201) 262-0010 to schedule an appointment with our Veterinary Nutritionist:

Yes

No, I will call to make appointment

If Yes, Please List Date/Time:

Please enter the text below: