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Our Hospital
Our Doctors
Our Team
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Hospital Tour
Careers
AAHA Accredited
Payment Options
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PETDESK
Services
Laser Therapy
Cruciate Disease
Dental Care
View All Services
New Clients
New Patient Registration
Pharmacy
Contact Us
Make An Appointment
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Holistic Intake Form for Nutritional Consultations
Holistic Intake Form for Nutritional Consultations
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
No
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)
Select a choice
Once
Twice
3 times
More than 3 times
Food is out all the time
Does your pet finish all food that is offered?
(Required)
Yes
No
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
No
Have you observed any changes in defecation?
(Required)
Yes
No
Have you observed any changes in appetite?
(Required)
Yes
No
Have you observed any changes in activity level?
(Required)
Yes
No
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)
1
2
3
4
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
No
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)
1
3
5
7
9
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)
MM slash DD slash YYYY
Do you give consent for us to use photos of your pet(s) for educational purposes?"
(Required)
Yes
No
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