Veterinary Nutrition Diet History

 
Julie Churchill, DVM, PhD, DACVN
Associate Clinical Professor
Small Animal Nutrition
Clinic Phone: 612-624-5024
email: vetnut@umn.edu


 

CLIENT INFORMATION
 
 

PATIENT INFORMATION



OR (fill in one of the other)
Enter in years & months, i.e., 5 yrs, 3 mos
pounds
 


REFERRING VETERINARIAN INFORMATION



REASON FOR VISIT


PART I: HISTORY








     
  • pounds


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?
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?

     

     

How much exercise does your pet get daily?