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Extended 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 Screening Evaluation been completed?:

Changes in food intake or behaviour

Amount Eaten:

Chewing:

Swallowing:

Nausea:

Vomiting:

Regurgitation:

Condition of the integument

 
 
Easily plucked hair:

Thin Skin:

Dry or scaly skin:

 

Abnormalities in the serum chemistry profile

 
 
Glucose:


Albumin:


Total Protein:


Urea:


Creatinine:


SDMA:


TotalT4:


 

Abnormalities in complete blood count

Anaemia:

Lymphopenia:

 

Recommendations

Change in caloric intake recommended?:

kcal or kJ/day
kcal or kJ/day
Change in the diet recommended?:

Change in the feeding management recommended? :

Change of environmental factors recommended? (I.e. issues with multiple pets, other food providers and sources, extent of enrichment, activity of pet, environmental stressors.):

Recommendations for monitoring given to the client? (I.e. BW, BCS, MCS, food intake, appetite, gastrointestinal clinical signs, activity, overall appearance.):

Did the client purchase the recommended food?:

Educational Information and/or tools dispensed:

 

On completion, press SUBMIT (enquiries@congletonvets.com) where the form shall be forwarded to the relevant vet who should then communicate with the client. 

 
Security Question: