Veterinary Nutrition Diet History


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

Date:
UMN Case No.:
   
Client Name:
Client Address:
Phone No.:
Client Email:
   
Clinic:
Veterinarian:
Clinic Phone No.:
   
Pet Name:
Species:
Breed:
Pet Age:
 in  Months  Years      
Pet Sex:
 Male  Female  
Spayed/Neutered:
  Yes No   
Body Weight:  pounds 
Body Condition:
Overweight Normal  Underweight
   



Reason for Consult:


Your Pet's Health
Please list your pet's current and past medical problems, if any, and whether they have been resolved:
Please list all medications your pet is currently receiving and any administered over the past three months (indicate medications that are current):

Do you give your pet any nutritional supplements? List names of product, amount and frequency:

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 whether your pet has experienced any of the following:
Recent change in appetite?   Explain 

Recent unintended weight change?   Over what time period? 

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? 

Diarrhea    times/day   times/week    Over what time period? 

Current Diet

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
Number
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 Diets
Food
Form
Amount
Number
Fed since

Have you made recent changes in diet (last 4 weeks)?   Yes     No     If yes, please note what the change was and why you made it:

ENVIRONMENT:

Who Feeds?      
Where 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  
Amount of exercise daily?  

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