Part A:Nutritional History Sheet Canine: Initial Screen to be
filled out by client
Ideal Weight (kg)
Very thin Thin Ideal Over Weight Obese
1 2 3 4 5
Mild Moderate severe
Activities None Walk Obedience Sports Working Other
Activity Level Low Medium Hard Intense
Temperament Calm Happy Nervous Aggressive Timid
Nutritional Screening (Please weight the amount you feed per day or bring the food in a zip lock bag to be weighted)
Present Diet: How much?
Snacks or Treats: How Many?
Dietary Yes No Names of
When did you last
change the diet?
Altered Yes No Treatment
gastrointestinal Vomiting Loose Stool
function Circle and
Skin and Ear Yes No Treatment
Problems: Circle Smelly Dry
and add comments
Itchy Hair loss
Part B: To fill out if you have requested a nutritional consult Referring Clinician:
Also Please fill out Part A
Present Diet Amount (Please weigh in g or bring in one daily serving In a Ziploc bag for
us to weigh
Treats Type and How Water source Approx.
Often How Much does pet
drink per day?
Any other pets Yes No Number/Type/
in House Age
Access to other food, garbage, neighbour’s, livestock
Medical /Surgical Information
Medication Type/Dose/Last treatment
Recommendations (Attach additional Information)
Note this goes on the back of sheet 1 in the medical records
Update Nutritional History: Owner: Case #:
Check at each visit
Date Update Signed