Please answer the following questions about your pet:Date MM slash DD slash YYYY Pet NameSpecies Feline Canine Other BreedDate of birth/AgeSex Male Intact Male Neutered Female Intact Female Spayed Reason for Visit:Is your pet: Indoor only Outdoor only Indoor/Outdoor How much exercise does your pet get each day? Never Less than daily <15 mins <30 mins <45 mins <1 hour >1 hour Describe the exercise (run, walk, fetch, pulling, agility, etc.))Do you have other pets? Yes No If you have other pets, are your pets fed separately? Yes No Does this pet have access to any other pets' food? Yes No Does your pet have good appetite? Yes Sometimes No Has your pet's appetite recently: Increased Stayed the same Decreased Has your pet recently: Gained weight Maintained weight Lost weight If your pet has gained or lost weight recently, was that intentional? Yes No Please list your pet's medical issuesWhat medications is your pet taking (along with the dose of each)MedicationDose Add RemoveDo you give any dietary supplements to your pet such as fatty acids or joint supplements? Yes No If yes, please list brands and amountsBrandAmount Add RemoveDo you use any flavored medications? Yes No If yes, please describe types and frequencyTypeFrequency Add RemoveDo you use food to administer medications or supplements to your pet? Yes No If yes, please describe what type of food is used and how muchFood TypeHow much Add RemoveHave you made any recent changes to your pet's diet (in the last 4 weeks)? Yes No If yes, please note what the changes was and the reason for making it.Changes madeReason for change Add RemoveDoes your pet have food preferences, such as for wet food or dry food? Wet Food Dry Food No Preferences Does your pet refuse to eat certain foods? Yes No If yes, please describeDoes you pet have any adverse reactions to foods/food allergies? Yes No If yes, please describe and detail the reactionPlease list brands, product names, sizes, and amounts of ALL foods, treats, human foods, snacks, dental hygiene products, rawhides, and any other foods that your pet is currently eatingFood including flavor, descriptors, and size (if applicable)Form (wet / dry / treat)Amount per dayFed since Add Remove*if you feed by volume, what type and size of measuring device do you use?*if wet food is fed, what size container (can, pouch, or other) is used?Does your pet have access to other food sources, besides what you feed him? Yes No If yes, please describeWho feeds your pet?If you have changed the diet recently, please list any other commercial or home-preparred diets you are not currently feeding but have fed in the last 2-3 months To find a Board Certified Veterinary Nutritionist®, please go to www.acvn.org/directory The circular ACVN logo, "ACVN", and "Board Certified Veterinary Nutritionist" are registered trademarks of the American College of Veterinary Nutrition NameThis field is for validation purposes and should be left unchanged.
