Veterinary Nutrition Diet History
Julie Churchill, DVM, PhD, DACVN
Associate Clinical Professor
Small Animal Nutrition
Clinic Phone: 612-624-5024
email:
vetnut@umn.edu
Note: This is not an appointment request, Please call to schedule an appointment before submission.
Today's Date
UMN PA Number / Case Number
CLIENT INFORMATION
Client Name*
Client Address
City
State
Zip
Phone Number
Email
PATIENT INFORMATION
Pet Name*
Species
Breed
Gender
Choose...
Female, Intact
Female, Spayed
Male, Intact
Male, Neutered
Other
Birthdate
OR (fill in one of the other)
Age
Enter in years & months, i.e., 5 yrs, 3 mos
Body Weight
pounds
Body Condition
Overweight
Normal
Underweight
REFERRING VETERINARIAN INFORMATION
Clinic Name
Clinic Phone
Referring Veterinarian Name
REASON FOR VISIT
Reason for Visit
PART I: HISTORY
1. Please list your pet's current and past medical problems, if any, and whether they have been respolved.
2. Please list all medications your pet is currently receiving and any administered over the past three months (indicate if the medication is current or previous). i.e., current: prednisone, 5 mg, orally, every other day
3. Do you give your pet any nutritional supplements? List the name, amount and frequency of each product.
4. How do you administer medications and supplements to your pet? If foods, such as peanut butter or Pill Pockets are used, please estimate amounts fed per day.
Please indicate whenter your pet has experienced any of the following:
Recent change in appetite?
Recent unintended weight change?
Over what time period (days, weeks, years)
Weight Gain / Loss / Stable
Weight Gain
Weight Loss
Weight Stable
If weight gain or loss, how much
pounds
Vomiting
times / day
times / week
over what time period (i.e., days, weeks, months, years)
Diarrhea
times / day
times / week
over what time period (i.e., days, weeks, months, years)
CURRENT DIET HISTORY
Please list below the brands and product names (if applicable) and amounts of
ALL commercial foods, human foods and treats
your pet is currently eating. This description should provide enough detail that we could go to the store and purchase the exact food. It should include "people foods" given as treats or at the table.
Food
Form
Amount
Frequency
Fed Since
Examples:
Purina Dog Chow
90% lean hamburger, pan fried
Milk bone, medium
dry
dry
1 1/2 cups
3 oz.
2
2x / day
1x / week
3x / day
January 2004
May 2009
August 2008
PREVIOUS DIET HISTORY
Food
Form
Amount
Frequency
Fed Since
Have you made any recent changes in your pets diet in the last 4 weeks?
Yes
No
If yes, please note what the change was and why you made it:
ENVIRONMENT
Who feeds your pet?
Where is your pet fed?
Do other pets have access to this pet's food dish?
Does this pet have access to other pets' food dishes?
Indoor?
Yes
No
Outdoor?
Yes
No
How much exercise does your pet get daily?
Submit form