Nutrition Consult Request

UGA Veterinary Teaching Hospital
Clinical Nutrition Service
Comprehensive Nutritional History Form

Thank you for completing this form. The information you provide helps the Clinical Nutrition Service better understand your pet’s medical history, current diet, and lifestyle prior to your appointment.

Please answer all questions as thoroughly and accurately as possible. This may take 30-60 minutes. We recommend completing the form at home with all current foods, treats, chews, medications, and supplements available.

1. Client Information

Client Name (First and Last)(Required)

Client Email Address(Required)

2. Pet Information

Pet’s Name(Required)

Age(Required)

Breed(Required)

Sex(Required)

3. Veterinary History

Please list the names of all veterinary clinics that have treated your pet.(Required)

Include your primary/family veterinarian and any specialty services (Internal Medicine, Cardiology, Surgery, Dermatology, etc.).

If you already have medical records available, please email them to [email protected].

Has your pet visited an emergency or urgent care clinic within the past 2 years?(Required)

Yes

If yes, please list the clinic name(s) and forward the records to [email protected].(Required)

4. Nutrition Concerns

What is your primary concern regarding your pet’s nutrition or diet?(Required)

Please be as specific as possible.

5. Weight History

Has your pet’s weight changed in the past 3 months?(Required)

6. Stool (Fecal) Quality

Over the past 3 months, which stool types has your pet had?(Required)

For a larger version of the fecal scoring chart, please use the accessible PDF version from Purina Institute (opens in new tab)

Select all that apply.

Score 1 – Hard, dry pellets

Score 2 – Firm but segmented

Score 3 – Log-shaped with moist surface

Score 4 – Log-shaped but very moist

Score 5 – Very soft piles

Score 6 – “Cow patty” consistency

Score 7 – Liquid diarrhea

Pure liquid/water or mucus only

7. Gastrointestinal Signs

In the past 3 months, has your pet experienced any of the following?(Required)

Select all that apply.

8. Urination Habits

In the past 3 months, have you noticed any changes in your pet’s urination?(Required)

Select all that apply.

Increased frequency of urination

Decreased frequency of urination

Inappropriate urination (in the house or outside the litter box)

Straining or difficulty urinating

Dribbling urine or weak urine stream

Strong or foul-smelling urine

Blood in urine (pink/red)

None of the above

9. Living Environment

Where has your pet spent most of their time in the past 3 months?(Required)

Indoors at home

Outdoors at home

Combination of indoors and outdoors

Boarding facility or daycare for extended periods

10. Exercise

How much exercise has your pet received daily in the past 3 months?(Required)

Please describe your pet’s typical exercise routine.(Required)

Examples: walking, running, swimming, physical therapy exercises, playing, etc.

11. Other Pets in the Household

Do you have other pets in your household?(Required)

Yes

Does your pet have access to another pet’s food or feces?(Required)

Yes

If NO, how do you prevent access to other pets’ food or feces?(Required)

Examples: feeding pets separately, elevated feeding stations, baby gates, covered litter boxes, etc.

12. Medications

Please list all medications your pet has received in the past 3 months.

Include the medication name, dose, frequency, and how it is given.

Example: Gabapentin 300 mg by mouth every 12 hours with food.

13. Parasite Prevention

Please list the brand names of all heartworm, flea, tick, or intestinal parasite prevention products your pet has received in the past 12 months.

Example: Heartgard®, NexGard®, Simparica Trio®, Bravecto®, etc.

14. Supplements

Please list any supplements your pet has received in the past 3 months.

For each supplement include:

Product name
Web link to the product
Who recommended it

15. Foods Used to Give Medications or Supplements

Please list any foods used to administer medications or supplements.

Include the brand name and approximate amount used.

Example:
½ slice Kraft Singles® cheese
½ tsp Jif® peanut butter (xylitol-free)

16. Diet Changes

Have you made any changes to your pet’s diet in the past 3 months?(Required)

Yes

17. Food Texture / Type

What types of foods does your pet routinely eat?(Required)

Select all that apply.

If "Other," please provide specific details.

18. Food Intolerances or Refusals

Are there foods your pet does not tolerate or refuses to eat?(Required)

Yes

If YES, please describe the food(s) and reaction observed.(Required)

19. Measuring Food

How do you measure your pet’s food?(Required)

Select all that apply.

20. Commercial Pet Foods

Please provide the exact web links for all commercial pet foods your pet has eaten in the past 3 months.

21. Human Foods and Homemade Diets

Please list any human foods or homemade diets your pet has been fed in the past 3 months.

Include:

Ingredients
Preparation method
Amount fed

Example: 3 oz roasted boneless, skinless chicken breast meat.
If feeding a custom homemade diet, please include the complete recipe and all supplements.

UGA Clinical Nutrition Service provides nutrition consultations through an initial in-person consultation followed by a follow-up consultation via Zoom or phone.

The initial consultation (up to 60 minutes) will include:

Medical and dietary history review
Physical examination
Discussion of recommended diagnostic testing

An estimate will be provided and approved before any diagnostic testing is performed.

Before leaving the initial visit, a follow-up consultation (up to 60 minutes) will be scheduled.

The Client Care Team can provide pricing information for both consultations.

A deposit is required prior to scheduling the initial consultation.

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Nutrition Consult Request

UGA Veterinary Teaching Hospital Clinical Nutrition Service Comprehensive Nutritional History Form

1. Client Information

2. Pet Information

3. Veterinary History

4. Nutrition Concerns

5. Weight History

6. Stool (Fecal) Quality

7. Gastrointestinal Signs

8. Urination Habits

9. Living Environment

10. Exercise

11. Other Pets in the Household

12. Medications

13. Parasite Prevention

14. Supplements

15. Foods Used to Give Medications or Supplements

16. Diet Changes

17. Food Texture / Type

18. Food Intolerances or Refusals

19. Measuring Food

20. Commercial Pet Foods

21. Human Foods and Homemade Diets

going beyond the expected

UGA Veterinary Teaching Hospital
Clinical Nutrition Service
Comprehensive Nutritional History Form