Medical Diet History Questionnaire

Medical & Diet History Questionnaire

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Pet Parent's Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Pet's Name(Required)

Birthdate OR Age (years / months)(Required)

Species(Required)

Canine

Feline

Breed(Required)

Color

Sex(Required)

Male

Female

Spayed or neutered?(Required)

Yes

Current Weight(Required)

Referring veterinarian Name(Required)

Prefix First Last

Referring Veterinarian's Veterinary Hospital Name:(Required)

Veterinary Hospital Address:(Required)

Street Address Address Line 2 City State ZIP Code

Veterinary Hospital Phone Number:(Required)

Veterinary Hospital Email:(Required)

Enter Email Confirm Email

Is the referring veterinarian your pet’s primary care veterinarian?(Required)

Yes

If NO, please list your Primary Care Veterinarian:

Prefix First Last

Primary Care Veterinary Hospital Name

Street Address Address Line 2 City State ZIP Code

Primary Care Veterinary Hospital Phone

Primary Care Veterinary Hospital Email

Enter Email Confirm Email

Has your pet also seen a specialist?(Required)

Yes

Veterinary Specialty

Veterinary Specialist Name:

Prefix First Last

Veterinary Specialty Hospital Name

Veterinary Specialty Hospital Address:

Street Address Address Line 2 City State ZIP Code

Veterinary Specialty Hospital Phone Number:

Veterinary Specialty Hospital Email:

Enter Email Confirm Email

How did you find us? (referred by, website, etc.):(Required)

Is your pet ideal weight, overweight, or underweight?(Required)

Ideal body weight

Overweight a little

Overweight a lot

Underweight a little

Underweight a lot

Please list your pet's medical diagnoses/concerns (or list healthy):(Required)

Please list all prior exact diets fed and amounts per day (e.g., Current diet: Purina Pro Plan Sensitive Skin Dry, 1 cup twice daily). Indicate most recent diet first and how long you have fed this food. It is also very helpful to send in photos of your current food or a link to the product online for reference (not needed for prescription diets).(Required)

Upload Photos of Current Food

Drop files here or

Max. file size: 64 MB.

Please list all treats your pet receives in exact quantity. If available, please list the calorie content of the treats. (Online links or photos of package labels are also helpful, these can be sent in email separately if needed).(Required)

Upload Photos of Current Treats

Drop files here or

Max. file size: 64 MB.

Please list all medications and supplements you are currently giving in exact quantity and frequency (i.e., 1. Prednisone 5 mg, every 12 hours; 2. Glucosamine 500 mg, once daily, etc.)(Required)

Please choose which PROTEINS your pet HAS EATEN before and also what he/she EATS WELL (leave blank if never eaten):

	Has eaten before	My pet eats well
Chicken
Liver
Beef
Pork
Lamb
Duck
Rabbit
Venison
Kangaroo
Ostrich
Bison
Fish
Scallops
Calamari
Eggs
Cheese
Cottage Cheese
Cream Cheese
Yogurt
Peanut Butter
Chickpeas
Pinto Beans or other beans
Tofu (soy or soybeans)

Please choose which CARBOHYDRATES your HAS EATEN before and also what he/she EATS WELL (leave blank if never eaten):

	Has eaten before	My pet eats well
Brown Rice
White Rice
Barley
Oats
Pasta
Quinoa
Amaranth
White Potato
Sweet Potato
Green Beans
Carrots
Corn
Spinach
Kale
Green Peas
Broccoli
Cauliflower
Zucchini
Squash
Butternut Squash
Pumpkin

Are there any other foods your pet has eaten that is not listed above?

Are there foods your pet will NOT eat?(Required)

Is your pet a picky eater or generally eats very well?(Required)

Are there any ingredients you want to INCLUDE in your recipe(s), if possible?(Required)

Are there ingredients you want to EXCLUDE or avoid in your recipe(s), if possible?(Required)

What do you hope to achieve with your nutrition consultation?(Required)

Please select the Nutrition consultation services you are requesting so we can provide an estimate for your review. Please email us at info@wholepetprovisions.com if you need a custom quote. Fee Schedule

Choose ONE appointment option(Required)

Nutrition Consultation Appointment with homemade diet formulation (1 recipe, 1 pet)

Nutrition Consultation Appointment with commercial pet food recommendations only (1 pet)

Nutrition Consultation Appointment with BOTH homemade diet formulation and commercial pet food recommendations (1 recipe, 1 pet)

Choose additional services (optional):

Additional formulated recipes

Specify how many additional recipes requested

The nutrition consultation will include vitamin/mineral supplement recommendations to balance the diet. We can also review therapeutic supplements for an additional charge.(see Therapeutic Supplement Reviews). PLEASE NOTE: If your pet is currently unstable medically or very ill, we do NOT recommend the Therapeutic Supplement Review with your initial consultation. Our goal is first to optimize and stabilize the diet. We are happy to add this service to a future recheck appointment. We can discuss this service during your appointment if you are unsure.

Are you also interested in a review of your pet's supplements or recommendations for a supplement plan? (Fee will be added to your estimate).(Required)

Yes

Recipes are formulated for individual pets as part of a medical consultation. The recipe is not to be distributed or shared with other pets. If you would like to feed the same recipe to additional pets, we will need to review that pet's medical records to confirm it is appropriate and calculate feeding amounts for that pet.(Required)