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Screening Evaluation Checklist

Diet History Review and Screening Evaluation Checklist

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

If you are a client and have been requested to fill in the questionnaire about your pet’s nutrition, please find and complete our Diet History Form.

 

Vet {Select from}:




Nurse {Select from}:




 
Pet's species:

Pet's gender:

Is Your Pet Neutered?:

Today
Has the diet history form been completed and reviewed:

Current body condition score (on 9-point scale):








Muscle condition score:



 

Nurtitional Screening Risk Factors (extended evaluation is OPTIONAL)

Extremely low or high activity:

Multiple Pets in a Household:

Gestation:

Lactation:

Growth Period:

Age of >7 years:

 

Nurtitional Screening Risk Factors (extended evaluation is MANDATORY)

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

 
Previous or ongoing medical conditions/disease:

Currently receiving medications and/or dietary supplements?:

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

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

Inadequate or inappropriate housing:

 

Physical Examination

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

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

Unexplained Weight Change:

Dental Abnormalities or Disease:

Poor skin or hair coat:

New medical conditions / disease:

 

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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