College of Veterinary Medicine

Veterinary Medical Center

Veterinary Nutrition Diet History Form

VMC2 – Image – 700x190 – nutrition

Julie Churchill, DVM, PhD, DACVN
Associate Clinical Professor
Small Animal Nutrition

Clinic service: 612-624-5024
vetnut@umn.edu

 

Date       UMN Case #

Client's Name

Client's Address

Phone #       Client's Email

Veterinarian    Clinic    Phone

Pet's Name       Species       Breed

Pet's Age  in  Months  Years         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 OR    Weight loss     How Much?   pounds     Weight stable

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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  • Last modified on July 5, 2013