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Diet History Form

This form will take about 15 minutes to complete. Please round up all foods, medications, supplements and treats prior to filling out. Providing specific information is very important as this is a telehealth appointment and omission of details could delay diet plan. The information in this form, in addition to your pet’s medical record will allow us to make the best and most expeditious nutritional recommendations.



Who feeds this pet?
Are there Children in the home under the age of 10?
Other pets in the house?
Does your pet have access to other pet food? (example: fed from the same bowl, or steals the kitten’s food) YES or NO If YES, please describe
Is your pet a food stealer/ trash raider: Does your pet ever gain access to the trash?


Where does your pet spend most of its time?
Is your pet:


Current Medications and Supplements (Name , BRAND and Dose per day):
Day 1
Day 2
Day 3
Day 4
EXAMPLE: Nutramax Dermaquin Plus for Dogs (1300 mg Omega-3 fatty acids, 680 mg EPA, 450 mg DHA per teaspoon): 1 teaspoon once daily. Please don’t just list “fish oil” or “joint supplement”


Homemade (human food) diet History:

Treat history: Commercial (store bought) or homemade

If your dog has gastrointestinal (stomach, intestinal) disease or skin disease please fill out the below. If your dog does not have these conditions you do not need to fill out the below.

Please select protein ingredients your pet has consumed in the past or is currently eating. Please also indicate if there are any ingredients you would prefer to use or avoid using in a homemade diet.

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