Nutritional Assessment Form

Owner’s Name: *

Date

Pet’s Name: *

Pet’s Age:

Breed:

Weight: (if known):

Sex:

Spayed/Neutered:

History/Lifestyle:

How many other pets are in the household?

# of dogs

# of cats

# of other

Who primarily feeds the pet in your household?YouAnother adultChild/ChildrenMultiple people

Where does your pet spend most of its time?

% of time indoor

% of time outdoor

How active is your pet each day?Very active (2+ hrs)Less active (30-45min)Moderately active (1-2hrs)Fairly active (less than 30min)

How would you describe your pet’s weight?OverweightIdealUnderweight

Have there been any changes to your pet’s weight recently? If so, describe.

Does your pet have any medical conditions to your knowledge? If so, please describe and discuss any medications/treatments associated with those conditions.

Feeding Habits

Please list the brand(s), product name(s), and amount(s) of all food fed.

Food #1:

Amount (oz or cups)

Frequency

When started

Food #2:

Amount (oz or cups)

Frequency

When started

Food #3:

Amount (oz or cups)

Frequency

When started

Food #4:

Amount (oz or cups)

Frequency

When started

Food #5:

Amount (oz or cups)

Frequency

When started

Other (please specify)

Are routine health treats given? If so, please provide details.

Does your pet have any medication wrapped/disguised in food? If so, please provide details.

Do you use food as a reward or training aid? If so, what and how often?

Do you give any other treats or extras? If so, what and how often?

Does your pet eat human food/table scraps? If yes, please describe types of food, frequency, and amounts.

Are nutritional supplements given? If so, please describe brand, amount, and frequency.

Would you describe your pet as a picky eater? If so, any known aversions?

Does your pet share the food bowl with other pets?

Is your pet fed free choice (as much as they want) or fed measured amounts per day?

If meals are fed, what times of day are the meals?

If fed measured amounts, what is used to measure the amount of food given?Food scaleMeasuring cupOther

Does your pet beg for food? If so, when/what triggers the behavior?

On a scale of 1-5, how is your pet’s appetite? (1 is very poor and 5 is very good)

Do you feel like your pet has difficulty chewing or swallowing food?

Do you feel like your pet is nauseous? Does your pet vomit? If so, how often and please describe (e.g. undigested kibble vs foamy brown liquid)

Have there been any changes to your pet’s toileting habits recently? If so, please describe.

How would you characterize your pet’s stools using the 1-7 fecal score chart (attached)?

Have you noticed any of the following changes in your pet recently? If so please provide details.

Change in coat color?

Excessive moulting or hair loss?

Licking/nibbling at skin?

Any changes in drinking?

Any changes in urination?

Any changes in behavior?

Any other changes?

When it comes to purchasing pet food, how do you obtain your current diet?

Would you potentially be open to switching brands or ways you obtain the diet? If not, please provide details on what changes cannot be made.

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Nutritional Assessment Form

History/Lifestyle:

Feeding Habits

Please list the brand(s), product name(s), and amount(s) of all food fed.

Purina Fecal Scoring Chart

Body Condition Score

!Side Menu Images

!Mobile Content

!Header Logo

!Give us a call button

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!Call Icon

Nutritional Assessment Form

History/Lifestyle:

Feeding Habits

Please list the brand(s), product name(s), and amount(s) of all food fed.

Purina Fecal Scoring Chart

Body Condition Score