Diet History Form

Owner

First Last

Phone Number

Email*

Pet Name

Today's Date

What food(s) are currently fed at main meals?

Dry Food

Never
Occasionally/Small Portion
About Half
Mostly
Exclusively

If fed, what brands and amounts are fed most often:

Canned Food:

Never
Occasionally/Small Portion
About Half
Mostly
Exclusively

If fed, what brands and amounts are fed most often:

Home-Prepared Foods:

Never
Occasionally/Small Portion
About Half
Mostly
Exclusively

If fed, please provide recipes used:

Main Meals

(from above)

Dry

Quantity

Office Use

Canned

Quantity

Office Use

Home-Prepared

Quantity

Office Use

Pet Treats

Biscuits

Quantity

Office Use

Rawhide/Pig Ears, etc.

Quantity

Office Use

Table Food

Breakfast

Quantity

Office Use

Lunch

Quantity

Office Use

Dinner

Quantity

Office Use

Between Meals

Quantity

Office Use

Food used to cover medication

Quantity

Office Use

Additives to pet food for flavoring (gravy, broth, etc.)

Quantity

Office Use

Vitamins/Supplements

Owner/Environment Information

Have there been recent changes in foods or brands fed?

No
Yes

If so, when and why?

How is your pet’s appetite?

Good
Poor

Have there been any recent changes?

How frequently does your pet defecate?

Not every day
1-2/day
2-3/day
4 or more/day
Don’t know

How would you characterize his/her typical stool formation?

Firm/hard
Formed but not hard
Loose

Where does your pet spend most of his/her time?

Indoors
Outdoors
About half in and half out

How much time does your pet spend walking, playing or running each day?

Less than 30 min
30-60 min
1-3 hours
More than 3 hours
Mostly inactive, but more than 3 hours/day once or twice per week

Do you have any questions regarding your pet’s diet?

Who feeds your pet?

On average, how many hours a day is your pet home alone?

How many adults/children in the household?

How many pets in the household?

Types of pets?

Where does your pet eat?

Does the pet have access to another pet’s food?

No
Yes

Is there competition for food?

Is more than one pet fed out of one dish?

Is the pet prone to getting into the trash?

Is the pet contained in the yard or does he/she have access to the neighborhood?

How frequently is the pet boarded or in the care of someone else?

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Diet History Form

Diet History/Daily Pet Calorie Intake

Main Meals

Pet Treats

Table Food

Vitamins/Supplements

Owner/Environment Information

In this section

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