Our Services and Facilities

Owner's Last Name:

Pet's name:

Pet's age:

Pet's species:

Cat
Dog

Pet's gender:

Male
Female

Is Pet Neutered?:

Yes
No

Date form completed:

Today

Extremely low or high activity:

Yes
No

Multiple Pets in a Household:

Yes
No

Gestation:

Yes
No

Lactation:

Yes
No

Growth Period:

Yes
No

Age of >7 years:

Yes
No

Nurtitional Screening Risk Factors (extended evaluation is MANDATORY)

History of altered gastrointestinal function (e.g. vomiting, diarrhoea, nausea, flatulence, constipation):

Yes
No

Previous or ongoing medical conditions/disease:

Yes
No

Currently receiving medications and/or dietary supplements?:

Yes
No

Unconventional diet (e.g. raw, homemade, vegetarian, unfamiliar):

Yes
No

Snacks, treats, table food > 10% of total calories:

Yes
No

Inadequate or inappropriate housing:

Yes
No

Physical Examination

Body condition score less than 4 or greater than 5 (on 9 point scale):

Yes
No

Muscle condition score: Mild, moderate, or severe muscle wasting:

Yes
No

Unexplained Weight Change:

Yes
No

Dental Abnormalities or Disease:

Yes
No

Poor skin or hair coat:

Yes
No

New medical conditions / disease:

Yes
No

Pets that are healthy and without any risk factors need no additional extended evaluation.

If zero Yes responses, then the Nutritional Assessment is complete!

If any Yes responses, then continue to the Extended Evaluation Checklist.

Please note that blood and urine screening +/- faecal testing are required as part of this second phase.

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I have read and agreed to the privacy policy:

Screening Evaluation Checklist

This form is designed to be completed by one of our vets or registered veterinary nurses, at Congleton Vets

Nurtitional Screening Risk Factors (extended evaluation is OPTIONAL)

Nurtitional Screening Risk Factors (extended evaluation is MANDATORY)

Physical Examination

Screening Evaluation Checklist

This form is designed to be completed by one of our vets or registered veterinary nurses, at Congleton Vets

Nurtitional Screening Risk Factors (extended evaluation is OPTIONAL)

Nurtitional Screening Risk Factors (extended evaluation is MANDATORY)

Physical Examination

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