Date UMN Case #
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
Your Pet's Health
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:
Recent unintended weight change? Over what time period?
Vomiting times/day times/week Over what time period?
Diarrhea times/day times/week Over what time period?
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:
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?
Amount of exercise daily?