Nutrition Analysis Form | Tamara Tokash

Please fill out the Clinical Nutrition Questionnaire and hit the submit button when finished. The form should take 20-30 minutes to complete. After we speak, I will create a Customized Nutritional Protocol specifically designed for your dog. This detailed canine nutritional analysis will be tailor made and designed to achieve optimum health for your dog’s individual needs.

Prior to filling out the Nutrition Form, please e-sign the Letter of Agreement HERE.

Name of Guardian

Name of Dog (s)

Street Address

City

State

Zip Code

Daytime Phone

Cell Phone

Evening Phone

Email address

How did you hear about Courteous Canines?

Current Vet

Breed / Mix

Date of Birth

Coat Color

Spayed / Neutered/ Date

Adopted or Purchased

Adopted

Purchased

Number of animals in house

Current Diet. Please be specific – Brand, Name, etc.

Type of treats. Please be specific – Brand, Name, etc.

Number of Meals / Day

Where is dog fed?

Does your dog finish food meal right away?

Do you leave food out in bowl?

Does dog have any food intolerance's/sensitivities/allergies?

What specific issues would you like addressed?

Behavior around people

Behavior around animals

Does anything stress or irritate your dog?

On a scale of 1-10 what is your dog’s stress level? 1 = calm. 10 = being agitated.

Would you say your dog is tired, energetic yet calm, or nervous/anxious and fearful?

Current Medications

Vitamins/ Supplements

Medical History

Where does dog sleep?

Does dog gravitate towards cold or warmth?

Does dog pant a lot?

Yes

How much does your dog weigh?

Does your dog drink a lot or a little?

Do you use filtered / spring water?

Does your dog urinate a lot?

Do you use flea/tick preventative? If so please list name

Do you give heart worm pills? If so, please list name

Do you vaccinate your dog? If so, what vaccines have been administered?

How much time does dog spend outdoors? Attended and/or unattended?

Do you tie your dog up outside?

Is your dog in a pen / confined outside?

Is he/she on a leash with you or turned out in a fenced yard or invisible fence?

Is he/she accompanied outdoors to eliminate?

Dogs your dog prefer hot or cold weather?

Describe your dog’s tongue. Wet, dry, color & size.

Describe dog’s foot pads. Dry, cracked, smooth, texture & color.

Describe dog’s nose. Color, texture, wet or dry.

Describe dog’s skin

Has your dog ever had hot spots?

Is your dog micro-chipped?

Describe coat / fur

Describe ears. Warm, cold, odor and/or discharge.

Describe dog’s poop

Has your dog ever experienced any digestive issues?

Are you willing to feed raw or cook?

Do you know if your dog's littermates are dealing with a similar situation?

Comments

Are you scheduling an 'IN-HOUSE session or a TELEPHONE consult?

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