Clinical Nutrition Service
52 Campus Drive
Saskatoon, SK
Phone: 306-966-7126
Email: vmccorrespond@usask.ca
Website: www.usask.ca/vmc
DIETHISTORYFORM
(tobecompletedbypet’sownerorprimarycaretaker)
RequestType: AppointmentatWCVM-VMC Pleaseconsultwithmyprimaryveterinarian
ConsultwithmytreatingveterinarianatWCVM-VMC
Date:_________________VMCCaseNumber(ifapplicable):_______________________________________________________
ClientName(s)(firstandlast):_____________________________________________________________________________________
Address:______________________________________________________________________________________________________________
PhoneNumber(s):___________________________________________________________________________________________________
Email:_________________________________________________________________________________________________________________
Primaryveterinarian/Clinicname:_________________________________________________________________________________
ClinicPhone:____________________________________ClinicEmail:______________________________________________________
PetName:___________________________________________________________________Age:___________________________________
Breed:_______________Color:________________Sex: Male Female Spayed/Neutered:
Mostrecentbodyweight:______________ kg lbPet’sweightis: ideal overideal underideal
Reasonsandgoalsforconsultation:
PleasecheckALLthatapply:
Togetgeneralinformationaboutpetnutrition
Togetspecificinformationaboutthebestnutritionformypet’smedicalcondition(s)
Tofindanappropriatecommercialdietformypet,ifavailable
Toobtainabalancedhome-prepareddietformypet
Ifnoappropriatecommercialdietisavailable
Becausemypetwillnoteattheavailableappropriatecommercialdiets
Iprefertopreparemypet’sfoodathomeratherthanfeedcommercial
Other:___________________________________________________________________________________
Pleaseprovideanyadditionalexplanationforthisappointmentyoufeelareimportant:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Thefollowingitemsareneededinordertocompleteanappointmentorconsult.
Theseitemsarerequestedintheinterestofmakingthebestrecommendationsforyourpet.
Allbloodworkshouldbedatedwithinthepast6months;however,sickpetsmayrequiremorerecenttests.
Pleasecalloremailifyouhaveanyquestions.TestscanbeperformedbyyourregularvetorattheWCVM.
CompletedDietHistoryForm(allappointmentsorconsultrequests)
CompletedNutritionConsultRequestForm(tobecompletedbyyourveterinarian)
Completebloodcount(CBC),biochemistryprofilewithelectrolytes,urinalysis(UA)
T4(thyroidfunctiontesting)inolderpetsoroverweightdogsorunderweightcats
Additionaldiagnostics(e.g.urineculture,UPC,ultrasoundorbiopsyreports,etc)
*Ifcasehistoryindicatesthatotherdiagnostictestsareneeded,thesemaybe
requestedpriortoadietformulationbeingprovided.
Medicalrecordsforthepast6monthsORallrecordsthatarerelevanttocasehistory
HouseholdQuestions:
Howmanyadultsareinthehousehold?_______Howmanychildren(ages)?___________________________________
Doyouhaveotherpets?___________Ifyes,pleasespecify__________________________________________________________
Ifyes,aretheyfedseparatelyortogether?_____________Dotheyhaveaccesstotheother’sfood?____________
Isfood alwaysavailable onlyavailableatspecifictimes(when?__________________________)
Whofeedsthispet?___________________Howmanymealsperday?_____________________________________
Howisyourpet’sfoodstored?_____________________________________________________________________
Questionsspecifictothispet:Mostrecentbodyweight:______________ kg lb
Ithinkmypet’sweightis: ideal overidealweight underidealweight
Hasyourpetlostorgainedweightrecently?_____________Ifso,whenwasitnoticed?_________________________
Ifso,estimatetheamountorprovidethepreviousweight(s)anddatesifknown:____________________________
_________________________________________________________________________________________________________________________
Wastheweightchangeintentionalorunintentional?____________________________________________________________
Isyourpethoused: primarilyindoors primarilyoutdoors bothindoorsandoutdoors
Yourpet’sactivitylevelis:
verylow(mostlyacouchpotato)
low(shortwalks,occasionaltriptothepark,playswithtoysoccasionally/rarely)
average
aboveaverage(routinehikes/jogging,playsfetch/otherexercisemultipletimesaday)
high(dailyworkingdogssuchasfarmdogs,sleddogs,other)
Pleasedescribeyourpet’sactivityandanyrecentchanges:
________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Yourpet’sappetite:
Currentoverallappetite:
Excellent(eatsallfood,allofthetime,assoonasitisoffered)
Good(eatsmostfoods,mostofthetimeoreatsallfoodofferedbuttakestime)
Fair(eatssomefoods,needsoccasionalcoaxing)
Poor(eatsonlysomefoodsand/oronlysmallamounts,evenwithcoaxing)
Absent(won’teatanythingoffered)
Variable(eatssomefooditemswithgood/excellentappetiteonsomedaysbutmayeatsotherfoodsor
samefoodsonotherdayswithapoor/fairappetite)
Ifappetiteisvariable,pleaseexplainandspecifypreferredfoods:______________________________________________
_________________________________________________________________________________________________________________________
Hasyourpet’sappetitechanged? Yes No
Ifyes,pleasedescribehowithaschangedandwhenyoufirstnoticedthischange:
_________________________________________________________________________________________________________________________
Hasyourpet’sfoodpreferencesorattitudetowardsfoodchanged?____________________________________________
Ifso,pleasedescribe:________________________________________________________________________________________________
Doesyourpetcurrentlybegforfoodbetweenmeals Yes No
Ifyes, Always(regardlessoffoodout) Onlyforspecificfoods(pleasedescribe)
_________________________________________________________________________________________________________________________
Willyourpeteattreatsorhumanfoodsiftheyareoffered?_____________________________________________________
_________________________________________________________________________________________________________________________
MedicalHistory:
Pleaselistthispet’sCURRENTmedicalproblemsandifthereisadiagnosis/knowncause:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Pleaselistthispet’sPASTmedicalproblemswithapproximatetime-frame,if/howtheyresolved,andif
therewasadiagnosis/knowncause:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PleaselistALLmedicationsANDsupplements(withdosages)thatyourpetisCURRENTLYreceiving.
Supplementsmayincludevitamins,herbs,glucosamine,fishoil,foodpowders,etc:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PleaselistanymedicationsandsupplementsyourpetisNOTcurrentlyreceivingbutwereadministered
overthepastthreetosixmonths:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Doesyourpethaveanyofthefollowing?Ifyes,pleaseexplain(howoften,howmuch,
sincewhen,etc):_______________________________________________
__________________________________________________________________
Involuntaryweightloss? Yes No__________________________________________________________________
Difficultychewingorswallowing? Yes No__________________________________________________________________
Nausea?
Yes No__________________________________________________________________
Vomitingorregurgitation?
Yes No__________________________________________________________________
Diarrhea?
Yes No__________________________________________________________________
Allergies?
Yes No__________________________________________________________________
Havetherebeenany:Ifyes,pleaseexplain(startingwhen,inwhat
way,howmuch,etc):__________________________________________
Changesinurination?
Yes No__________________________________________________________________
Changesindrinkingwater? Yes No__________________________________________________________________
Changesindefecation? Yes No__________________________________________________________________
Changesinappetite? Yes No__________________________________________________________________
Changesinactivitylevel? Yes No_________________________________________________________________
CURRENTDIET
*Pleaselisttheproductbrand,name,specificflavor(ifapplicable),amounts,andfrequencyfedforALL
foods,snacks,andtreatsyourpetisCURRENTLYeating.Pleasebeasaccurateaspossible.Thismay
requiretheuseofakitchenscaleorothermeasuringdeviceorforyoutokeepafoodjournalforaweek
ormoretotracknormalfeedingpatterns.
*Itshouldinclude“peoplefood”fedastreatsonaregularbasisoraspartofacurrenthome-cookeddiet.
*Itshouldbespecificenoughthatwecouldgotothestore,figureouthowtopurchasetheEXACTSAME
foods,andfeedthesameamountsyoudo.Youcanalsoincludepicturesoffoodsandpackagingifyouare
uncertainwhatinformationtoprovide.
BrandFood/variety
TypeAmount Howoften Fedsince
perfeeding
Examples:
PurinaDogChowDry 1½cups2x/dayJan.2014
MapleLeaf
Chickenbreasts Grilled
8oz/237gramsOnceperday
April2015
----
BananaORappleFresh½whole1xperdayJuly2013
MilkBone
MediumBiscuitDry1biscuit3x/daySept.2013
NutroSmallBreedAdult:SavoryWetImixasmallbitinwith2x/dayJan2014
Lamb&VegetableStew dryfood.One100gtray
lasts3days…
Howaremedicationsorsupplementsadministered?____________________________________________________________
Ifgivenintreats/specialfoodsotherthanthosealreadylistedabovepleaseestimatetheamountsusedper
daybelow.Example:3beefflavoredpillpockets,capsulesize,perday;¼teaspooncreamypeanutbutter
perpillx5pillsperday=1&¼tspperday;1/4ozor7gramsofcheddarcheesefor1pillperday,etc.
_________________________________________________________________________________________________________________________
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Doesyourpetpotentiallyhaveaccesstounmonitoredfoodsourcesyoumayormaynotbeawareof(i.e.
fromaneighbor,anotherpetinthehouse,smallchildren,catchesprey,etc)?
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PREVIOUSDIETSAND/ORFOODS,TREATS,ETC.(notcurrentlyfed):
*Pleaseincludeasmuchinformationaspossible
BrandFood
TypeAmountFrom–toReasondiscontinued
(ifknown)
.
Examples:
Hill’sScienceDietPuppyformuladry½-1cupperdayJan–Dec2011Becameadult
“X-brand”Adultlite,beefflavorcanned1canperdayJune–July2012Diarrhea
PleaselistANYotherfoods,treats,supplements,orotherdietarycomponentsthathaveEVER
beenfedthatwerenotcoveredinaprevioussection?Pleaseexplain:
**thisisespeciallyimportantforpetsthatmaybesufferingfromadversereactionstofoods.Pleaseprovide
asmuchdetailasyoucan.Anexampleisnotingthatsalmonisfedinsmallamountswhenyouprepareit
occasionallyathomeforyourself,butisnotroutine.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
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Whatismostimportanttoyouwhenchoosingapetfood?
PleasepickthetopthreethingsMOSTimportantorofthemostconcerntoyou:
Price/value
Convenience
Qualityofingredients
Presenceorabsenceofspecificingredients
Natural/holistic/organic(pleasecircle)
Safetyandresearchbehindfood
Doesmypetlikeit(palatability)
Doesitaddressmypet’sindividual/uniquemedicalorotherneeds
Other:____________________________________________________________________________________________
PleasecompletethefollowingONLYifyoumaybeinterestedinahome-prepareddiet:
Pleaserank(inorderofpreference)thetop3ingredientsfromEACHlist.Ifwecannotaccommodateyourrequests,wewill
contactyou.Pleasenotethatmorecomplexmedicalcondition(s)resultinmorelimitedingredientoptionsappropriateforapet.
Meat/poultry/seafoodsources:
Item
Eatswell Willnoteat
Adversereactionwhen Never
PreferNOTto
WillNOT
fed(describe)
tried
feedbutwill
feedthis
Beef
Chicken
Turkey
Egg
Pork
CottageCheese
Lamb
Yogurt
Tofu
Catfish
Tilapia
Cod
Tuna*
Shrimp
Otherfish/seafood ________________
Duck
Rabbit
Venison
Bison
Other_____________
*maynotberecommendedforlongtermfeedinginsomecases
Carbohydratesources:
Item
Eatswell
Willnoteat
Adversereaction
whenfed(describe)
Never
tried
PreferNOTto
feedbutwill
WillNOT
feedthis
Whiterice
Brownrice
Whitepotato
Sweetpotato
Barley
Polenta(corn)
Oatmeal
Pasta(wheat)
Quinoa
Greenpeas
Tapioca(pearl)
Bread(wheat)
Lentils
Beans
Other_____________
Other_____________
Pleaseprovideanyadditionalinformationyoufeelwouldbehelpful.
Forexample,thatyouareconcernedaboutcost,easeofpreparation,orcannotpreparecertainfoods:
_________________________________________________________________________________________________________________________________________________
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