Holistic intake form | Dunckel Veterinary Hospital

Thank you for taking the time to fill out this form. Please answer all questions as completely as you can

Owner's name(Required)

Pet's name(Required)

Pet's age(Required)

Species(Required)

Breed(Required)

Weight(Required)

Spay/Neuter status(Required)

Male

Male Neutered

Female

Female Spayed

Date(Required)

Nutrition plays an important role in your pet’s health, and providing the following information is vital in helping us understand your pet’s unique needs as well as your perspectives.

In order for us to make the best recommendations for your pet, the following items are requested. For sick pets, more recent lab results may be needed. Please call us at 810-653-3988 if you have any questions.

Intake form for nutrition consultations

Medical records from primary care veterinarian

Complete blood count, biochemistry profile and urinalysis from within the past year

Additional relevant test results (urine culture, T4, ultrasound reports, etc.)

What are your reasons and goals for a nutrition consultation?(Required)

Please answer the following questions about your pet

How is your pet housed?(Required)

Indoors

Outdoors

Please describe your pet’s activity level(Required)

No Activity (sick, injured, or geriatric dog)

Low (indoor only)

Some activity (leashed walks for less than 1 hour)

Moderate (outdoor time and activity more than 1 hour per day)

Active (regular daily exercise and fun, action packed weekends)

Highly Active (runs, hikes, swims, plays hard daily)

How many other dogs are in the household?(Required)

How many other cats are in the household?(Required)

Do any pets have access to other pets’ food?(Required)

Yes

How many other people live in your household?(Required)

Who feeds your pet?(Required)

How many times per day do you feed your pet?(Required)

Does your pet finish all food that is offered?(Required)

Yes

Does your pet have any of the following? Yes, no. If yes, please explain(Required)

Difficulty chewing

Difficulty swallowing

Involuntary weight loss

Nausea

Vomiting

Diarrhea

Allergies (include food)

Please explain

Have you observed any changes in urination?(Required)

Yes

Have you observed any changes in defecation?(Required)

Yes

Have you observed any changes in appetite?(Required)

Yes

Have you observed any changes in activity level?(Required)

Yes

Please explain urination changes

Please explain defecation changes

Please explain appetite changes

Please explain activity level changes

As you pet, hold and cuddle your dog, and observe your dog's behavior, which of the following best describe your dog? Please check all that apply.(Required)

Skin is hot to the touch

Dog pants often

Has excessively dry skin

Tends to lay in sun

Tends to lay in shade

Slow, lazy, or “down” demeanor

CURRENT DIET

How many pet(s) diets do you need to input?(Required)

Please upload pictures of your pet's diet

Max. file size: 50 MB.

1) Food Brand(Required)

1) Type (dry, can, raw, freeze dried, treats)(Required)

1) Amount per meal per(Required)

1) Fed how often?(Required)

1) What do you use to measure?(Required)

1) Fed Since?(Required)

2) Food Brand

2) Type (dry, can, raw, freeze dried, treats)

2) Amount per meal per

2) Fed how often?

2) What do you use to measure?

2) Fed Since?

3) Food Brand

3) Type (dry, can, raw, freeze dried, treats)

3) Amount per meal per

3) Fed how often?

3) What do you use to measure?

3) Fed Since?

4) Food Brand

4) Type (dry, can, raw, freeze dried, treats)

4) Amount per meal per

4) Fed how often?

4) What do you use to measure?

4) Fed Since?

ADDITIONAL QUESTIONS

Supplements: If your pet is taking any supplements, please list all products, including vitamins, joint supplements, fatty acids, herbal products, etc. Include brands, amounts, and frequency given.(Required)

Medications: If your pet is taking any medications, please list all drugs, dosages, and frequency given.(Required)

Food with medications: If you use food to give medications to your pet (for example, Pill Pockets, cheese, peanut butter, etc.), please list all foods, amounts, and frequency given.(Required)

Recent diet changes: If your pet’s diet has changed in the past 4 weeks, what changes were made and why?(Required)

Past diets: Please list all other diets you are not feeding now, but have fed to your pet in the past. Include when and why you stopped feeding each product.(Required)

Are you requesting a home-cooked diet recipe for your pet?(Required)

Yes

You can tell a lot about your dog by checking their tongue. Use the guide at the right to help you choose which best describes your dog.(Required)

Pale pink/almost light purple

Light pink

Bright pink

Red

Using the images below, choose the image number that most closely matches your pet’s shape/weight.(Required)

STATEMENT OF OWNERSHIP AND CONSENT: Thank you for completing the intake form for a nutrition consultation.

I am the owner and/or agent of the above animal and have the authorization to consent to treatment if and when it is needed. By signing this agreement, I authorize Dunckel Veterinary Hospital staff to provide care and perform any treatment.

Owner/Authorized Caregiver Signature(Required)

Date(Required)

Do you give consent for us to use photos of your pet(s) for educational purposes?"(Required)

Yes

CAPTCHA

Holistic Intake Form for Nutritional Consultations

Please answer the following questions about your pet

CURRENT DIET

ADDITIONAL QUESTIONS