Veterinary Nutrition Diet History | U of MN Vet Med Center

University of Minnesota Veterinary Medical Center Nutrition Diet History Questionnaire header

Julie Churchill, DVM, PhD, DACVN
Associate Clinical Professor
Small Animal Nutrition

Clinic Phone: 612-624-5024
email: vetnut@umn.edu

Note: This is not an appointment request, Please call to schedule an appointment before submission.

The following form has been broken out into 5 sections. At the end of each sectiton you will be able to save before going on to the next section. The sections are broken down into:      Section I: Client/Patient/Referring Veterinarian Information
     Section II: Medical History
     Section III: Current Diet History
     Section IV: Historical Diet History
     Sectiton V: Environmental Questions

Upon completion of the Environmental Factors section you will have a chance to review all of your answers. After you have reviewed them you will be asked to Submit your form. Upon submission you should receive an email at the email address you have provided in the Client Informatiotn section. The form is also submitted to the University of Minnesota Veterinary Medical Center Nutrition Department for review.

If you are feeding your pet a homemade diet, please e-mail the recipie to vetnut@umn.edu

Today's Date

UMN PA Number / Case Number

CLIENT INFORMATION

Client First/Last Name

Please enter your first and last name.

Client Address

Please enter your home address.

City

State

Zip Code

Phone Number

Please enter a phone number where we can reach you.

E-mail

Please enter a valid e-mail address. You will receive communication about this form submission at this address.

PATIENT INFORMATION

Pet's Name

Please enter your pet's name.

Species

Breed

Gender

Birthdate or Age or Enter in years & months, i.e., 5 yrs, 3 mos

Body Weight

pounds

Body Condition

Overweight

Normal

Underweight

RDVM & CLINIC INFORMATION

Clinic Name

Clinic Phone Number

Veterinarian Name

REASON FOR VISIT

Reason for Consult / Visit

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