Nutrition Consultation Request and Information Form

1.  Purina body condition score (1-9) ______

2.  Current weight ______

3.  Muscle wasting (check one): Absent Mild Moderate Severe

4.  Weight loss or gain in the past 6 months: Yes No

If yes, please specify dates and corresponding weights below.

Date / Weight / BCS (1-9)
kg lbs
kg lbs
kg lbs
kg lbs

5.  Activity level: Active Inactive Hospitalized Inpatient

6.  Appetite over previous month (circle one): Normal Hyporexic Anorexic

Appetite over past 24 hours or hospitalized period: Normal Hyporexic Anorexic

7.  Presenting complaint ______

8.  Provide problem list below. [Laboratory abnormalities will be listed in the following question]

9.  List any diagnoses

10.  Please list any biochemical abnormalities and any other significant laboratory values available (i.e., blood ammonia, urine protein:creatinine ratio) and the date upon which such tests were performed. Please also include pending tests. Provide previous thyroid panel results if screened in the past 6 months.

Chemistry:

Urinalysis:

Other:

Thyroid test within the last six months? Yes No If yes, results: ______

11.  Medications (including supplements and routine preventative medications):

How long have they received each of these medications?

Drug / Dose / Frequency / Length of time

12.  Do any of these medications contain contents or flavorings that could be important in this patient’s diet or disease? Yes No

(i.e., chewable heartworm preventative in patient with IBD)

If yes, please describe:

13.  What type and how much cat or dog food is this patient currently consuming? For dry food, please quantitate food based on an 8 oz cup or weight in grams. For canned food, please quantitate based on the amount of cans or weight of food in grams.

Type
(dry or canned) / Manufacturer / Specific name of diet (including flavor) / Amount fed
(8 oz cups, grams, or # of cans)

14.  Please list all treats fed. This includes all food items offered that are not the primary pet food (i.e., table scraps, pet treats, fast food). An estimate of how many treats per day and the size or weight of the item offered is invaluable.

Type of treat
(eg jerky, meat, carrots) / Manufacturer / Specific name of treat/size/weight
(i.e., Milkbone small) / Amount
(# fed or grams per day)

15.  If different, please describe as above what this patient was eating prior to his or her current illness.

Type
(dry or canned) / Manufacturer / Specific name of diet (including flavor) / Amount fed
(8 oz cups, grams, or # of cans)

Treats:

Type of treat
(eg jerky, meat, carrots) / Manufacturer / Specific name of treat/size/weight
(i.e., Milkbone small) / Amount
(# fed or grams per day)

16.  Exercise habits: Rank each of following with 5 high and 1 low (duration and distance is more important than speed)

Indoor activity: 5 4 3 2 1

Outdoor yard size: 5 4 3 2 1

Additional details:

Outdoor yard activity (hours):

Length of average walk:

On leash? Yes No

If possible, please quantify this patient’s total daily exercise by either distance or time (i.e., miles walked or hours of exercise). Time______Distance______

Is this patient primarily confined indoors? Yes No

If kept indoors, is this patient active or more of a couch potato indoors? Check one.

How long does he or she spend in the yard per day? ______
Size of the yard? ______

Is osteoarthritis a significant problem for this patient? Yes No

If yes, explain: ______

17.  Other pets:

Is this the only pet in the household? Yes No

Do any of the other pets have special food needs? Yes No

If so, what? ______

Can all pets be fed separately? Yes No

18.  Requesting Clinician______

Requesting Student ______

Special requests to be answered (e.g. evaluation of nutraceutical, anti-emetic, or related therapies) if applicable: