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    Nutritional Assessment Checklist Ipdf Pag1

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    Avinash Rana

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    Nutritional Assessment Checklist Ipdf Pag1

    Uploaded by

    Avinash Rana
    19 views1 page

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    nutritional_assessment_checklist_ipdf_pag1

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    19 views1 page

    Nutritional Assessment Checklist Ipdf Pag1

    Uploaded by

    Avinash Rana

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Nutritional Assessment Checklist

    To be completed by the pet owner. Please answer the following questions about your pet:
    Pet’s name: _________________________________ Species/breed: _____________________________ Age: ___________________________

    Owner’s name: _______________________________ Date form completed: ___________________

    1 How active is your pet? Very active Moderately active Not very active
    2 How would you describe your pet’s weight? Overweight Ideal weight Underweight
    3 Where does your pet spend most of the time Indoor Outdoor Indoor & Outdoor
    Please list below the brands and product names (if applicable) and amounts of ALL foods, treats, snacks, dental hygiene products,
    rawhides and any other foods that your pet is currently eating, including foods used to administer medications:

    Food Form *Amount Number Fed since


    Examples:
    • Purina Cat Chow dry ½ cup 2x/day Jan 2010
    • 90% lean hamburger pan-fried 3 oz (85 grams) 1x/week May 2011
    • Milk Bone medium dry 2 3/day Aug 2012
    • Greenies Salmon Dental treat 2 daily Jan 2013

    *If you feed by volume, what size measuring device do you use? _______________
    *If you feed tinned/canned food, what size tins/cans? _________________________
    4 Do you give any dietary supplements to your pet (for example: vitamins, glucosamine, fatty acids, or any
    other supplements)? No Yes
    If yes, please list brands and amounts:_________________________________________________________________

    To be completed by the health care team:


    Has the diet history form been reviewed? No If not, please review the diet history form Yes If yes, please continue:
    Current body weight: __________________ Ideal body weight: _______________________________
    Current body condition score* _____/9 or ____/5 *Refer to the body condition scoring chart
    Muscle Condition Score: normal mild wasting moderate wasting severe wasting
    Screening evaluation checklist
    Pets that are healthy and without risk factors need no additional extended evaluation
    Nutritional screening risk factors (extended evaluation is OPTIONAL) Check if present
    Extremely low or high activity level
    Multiple pets in a household
    Gestation
    Lactation
    Growth period
    Age of >7 years
    Nutritional screening risk factors (extended evaluation is MANDATORY)
    History of altered gastrointestinal function (e.g., vomiting, diarrhea, 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-pt 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

    NO CHECKED ITEM(S) ON THIS PAGE? The Nutrional Assessment is complete


    CHECKED ITEM(S) ON THIS PAGE? Continue on the next page wsava.org

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