GENERAL INFORMATION:
Your full name:
Mailing address:
Email address:
Best number(s) to call you:
Pet’s Name:
Age/birthday: Breed:
Male or Female: Neutered or Spayed?
If your dog is an intact female, does this dog breed? If so, is dog pregnant at this time? Give the date of the last litter, how many puppies and were they delivered naturally or cesarean. Did she nurse her puppies? Is she currently nursing?
Describe your dog’s activity level and exercise habits. (this information is used to determine caloric needs, please provide details)
Circle which one applies:
I want to feed my dog exclusively a home cooked diet.
I want to feed my dog primarily a high quality commercial food and supplement with a home cooked diet.
I want to feed my dog primarily a home cooked diet and use commercially prepared food only occasionally.
Please include a picture of your pet, if available.
PERSONALITY PROFILE:
My pet tends to be: (circle all that apply)
Shy Nervous Aggressive Outgoing Friendly Adventurous
Controlling Easy Going Aloof Moody Playful Difficult
Eager to please Difficult to train Reluctantly obeys Sometimes obeys
Never obeys Always obeys Easily distracted Focused and obedient
When people come to visit, my pet: (circle one that best describes your pet)
Tries to hide or avoid interaction with guests, but remains calm.
Tries to hide or avoid interaction with guests and acts nervous (shaking, panting, etc).
Stays close to family member(s) and growls or nips when guests approach.
Stays close to family member(s) and becomes submissive when approached by guest.
Greets guests with a friendly/calm attitude.
Greets guests with excitement, but does not touch them.
Greets guests with physical contact (jumping, pawing, etc).
Greets guests with aggression.
When my pet socializes with other dogs: (circle one that best describes your pet)
My dog becomes submissive, but remains friendly and calm.
My dog is very friendly, confident and calm.
My dog becomes submissive and nervous or fearful.
My dog tries to control or overpower other dogs.
My dog is too aggressive with other dogs to socialize.
My dog is extremely excited and playful. Often initiating play between dogs.
My dog barks at the other dogs but will not interact or play.
FEEDING HISTORY:
My dog currently eats the following foods: (include EVERYTHING you feed your dog. We are not judging you J We need to know what his/her stomach can or can not handle)
List any commercially prepared dog foods you have tried in the past and explain why you switched.
Describe (in detail) any home cooked diets you have prepared for your dog. How did he/she respond? Why did you stop using this diet?
List all foods that have given your dog GI upset? (vomiting/diarrhea)
Has your pet been food allergy tested? If so, please provide a copy of the allergy report.
Does your pet require a vegetarian diet for any reason. If so, describe.
Medical History:
List all medications and/or supplements you currently give your pet:
Describe any current medical conditions. This includes injury, abnormal blood work or acute illness.
Describe any recurring medical conditions and list medications you have used. This could include itchy skin, vomiting, intermittent limping, etc. Anything you have paid a vet to treat, list it here.
What is your pets BCS? (call veterinarian for this information)
Provide a current CBC and chemistry panel. We prefer this be performed immediately before requesting the diet. However, it is acceptable to provide results obtained within the last 30 days - IF the results were NORMAL and there have been no symptoms if illness since then.
Please list your veterinarian’s name and phone number:
