Nutrition/Integrative Medicine Service Patient History of patients being seen at BluePearl in Georgia

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1 Nutrition/Integrative Medicine Service Patient History of patients being seen at BluePearl in Georgia Please complete and bring this form WITH YOUR PET to your first appointment at BluePearl, along with all medications being given currently. Please contact us at or with questions. SECTION 1: CLIENT INFORMATION Client Name Pet Name Street Address City, State Zip Your Pet s Primary Care Veterinarian (Name) Primary Care Veterinary Hospital City, State Best Phone SECTION 2: PET MEDICAL HISTORY Species: Canine Feline Breed Age: Exact Approximate age How old was your pet when you adopted him/her? Sex (please check one): Male, not neutered Female, not spayed Male, neutered Female, spayed Current Medical Problems (save past problems for next section, please): Please check yes or no for each of the following: yes no Is your pet drinking more? yes no Is your pet urinating more? yes no Does your pet have a cough? yes no Does your pet sneeze frequently? yes no Does your pet vomit? yes no Does your pet have diarrhea? yes no Does your pet have any discharges? Patient History -- Page 1 of 5

2 Past problems or diagnoses and how long they ve been an issue for your pet: Past Medical Problems: Known food allergies: SECTION 3: PATIENT NUTRITION HISTORY Are there other animals in the household? If so, please describe species and number of each, such as 2 cats, 1 other dog, free roaming rabbit, etc. Is the food left out after meals or taken away? left out taken away other (please explain) Is your pet indoors, outdoors, or both? Please describe, for example, 100% indoors; or out during the day, in at night; or just goes out with me on walks; etc.: What kind of exercise does your pet receive and for how long each day, such as a 15-minute walk twice daily; ball throwing for a half hour daily; playing with laser pointer for 10 minutes daily; etc.? Type of exercise How long each time How many times per day How is your pet s appetite now? Patient History -- Page 2 of 5

3 Please list below all foods that you remember feeding (use back of page if necessary): Food Form Amount* Number of Fed when? s Royal Canin hypoallergenic venison Can ½ can (12 oz can) 4X daily Nov 2016 to present Lean hamburger Cooked ¼ cup 1X daily Nov 2016 to present Natural Balance duck and potato Dry 1 scoop (2 cup scoop) 2X daily Feb 2015 to Nov 2016 Homemade food See below 1 cup 3X daily * if you use a scoop that is not equivalent to an 8 oz kitchen measuring cup, please estimate how many cups it is. For cans, indicate size. For raw foods, indicate in oz Please list all TREATS and SNACKS (use back of page if necessary):: Brand Amount Number of s Large rawhide chew 1 8 inch bone 3 X weekly Fruitables 1 strip 2X daily Cheese ¼ piece Training treats maybe 10-15/day For homemade food, please describe in detail (use back of page if necessary):: Ingredients Amount (in cups or oz) Meats Carbohydrates Veggies Fruits Dairy Fats and oils Other food ingredients (supplements will be listed on the next page) Ground beef, 10% fat, cooked Cooked quinoa Raw turkey and bone grind (Primal brand) Spinach, raw pureed Powdered flax seed 2 cups 400 grams 12 oz ½ of 16 oz bag 2 tablespoons Times per day 2X once when she asks with meals once Patient History -- Page 3 of 5

4 What supplements is your pet being given? Please include all vitamins, fatty acids, glucosamine, other nutraceuticals and herbs. Do not list DRUGS here that is for the next table. Number of Supplement or herb name Dose given What drugs is your pet being given? Please include all that you get from your veterinarian AND over-the-counter from drug stores. Include heartworm and flea medications. Number of Drug name Dose given Patient History -- Page 4 of 5

5 SECTION 4: TYPE OF THERAPIES AND GOALS OF TREATMENT What are the goals of our visit today? What would you like to accomplish? Are you interested in discussing natural therapies such as herbs and acupuncture? yes no SECTION 5: HOMEMADE DIET PREFERENCES: Please skip this section if you are not interested in a homemade diet. Homemade diets are recommended as an option in many cases due to their flexibility and unique nutritional content. Please note that homemade diet formulation is an extensive, time-consuming process and if requested, there is an additional charge for this service. Formulation generally takes 2-3 weeks. INGREDIENT PREFERENCES Choose one or more proteins Beef Pork Lamb Chicken Turkey Egg Tuna Salmon Tilapia/whitefish Mackerel Rabbit Cottage Cheese Tofu Chickpeas Signature: Choose one or more carbohydrates White rice Brown rice Barley Oatmeal White Potato Sweet Potato Green peas Pasta Polenta/Grits Millet Quinoa Tapioca Amaranth Corn Date: Choose veggies (optional) Spinach Carrots Broccoli Cauliflower Green beans Summer squash (yellow, zucchini) Winter squash (acorn, spaghetti) Zucchini Bell pepper Thank you for taking time to supply us with this information. Patient History -- Page 5 of 5

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