Clinical Animal Nutrition for Dogs

Name(Required)

First Last

Email(Required)

Patient Name

Group One – Sympethetic

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Dry mouth, eyes, nose

Please enter a number from 1 to 3.

Keyed up, fails to calm

Please enter a number from 1 to 3.

Nervous

Please enter a number from 1 to 3.

Unable to relax, startles easily

Please enter a number from 1 to 3.

Vomits with excitement

Please enter a number from 1 to 3.

Tends toward aggression

Please enter a number from 1 to 3.

Fear biter

Please enter a number from 1 to 3.

Bites out of fear

High anxiety

Please enter a number from 1 to 3.

Isolates away from family or pets

Please enter a number from 1 to 3.

Afraid of storms, fireworks

Please enter a number from 1 to 3.

Doesn’t adapt easily to routine change

Please enter a number from 1 to 3.

Obsessive compulsive behavior

Please enter a number from 1 to 3.

Group One Total

Total of number marked

Group One Percentage

Number divided by 36

Group Two – Parasympathetic

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Joint stiffness with rising

Please enter a number from 1 to 3.

Always seems hungry

Please enter a number from 1 to 3.

Couch potato-like attitude

Please enter a number from 1 to 3.

Slow starter, slow mover

Please enter a number from 1 to 3.

Subject to infections

Please enter a number from 1 to 3.

Eyes or nose watery

Please enter a number from 1 to 3.

Eats dirt

Please enter a number from 1 to 3.

Constipation, diarrhea, alternating

Please enter a number from 1 to 3.

Poor circulation, sensitive to cold

Please enter a number from 1 to 3.

Moist body, often an odor

Please enter a number from 1 to 3.

Sleeps more than used to

Please enter a number from 1 to 3.

Little interest in anything

Please enter a number from 1 to 3.

Group Two Total

Group Two Percentage

Group Three – Carbohydrate Metabolism, Sugar Handling

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Trembles, episodes of weakness

Please enter a number from 1 to 3.

Seizures

Please enter a number from 1 to 3.

Disoriented at times

Please enter a number from 1 to 3.

Increased sleeping, decreased activity

Please enter a number from 1 to 3.

Wheat, corn, rice, barley, oats in diet

Please enter a number from 1 to 3.

Urinating large amounts

Please enter a number from 1 to 3.

Hungry often, eats fast

Please enter a number from 1 to 3.

Change in appearance of eyes

Please enter a number from 1 to 3.

Cannot lose weight even with diet

Please enter a number from 1 to 3.

Eats feces

Please enter a number from 1 to 3.

Weight loss

Please enter a number from 1 to 3.

Behavior changes

Please enter a number from 1 to 3.

Increased water consumption

Please enter a number from 1 to 3.

Overweight

Please enter a number from 1 to 3.

Passes a lot of gas

Please enter a number from 1 to 3.

Group Three Total

Group Three Percentage

Group Four – Circulation

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Exercise intolerance

Please enter a number from 1 to 3.

Significant loss of muscle mass

Please enter a number from 1 to 3.

Fainting, collapse

Please enter a number from 1 to 3.

History of heartworms

Please enter a number from 1 to 3.

Cough, especially at rest

Please enter a number from 1 to 3.

Seems disoriented at times

Please enter a number from 1 to 3.

Rear legs tremble, weak

Please enter a number from 1 to 3.

Enlarged heart

Please enter a number from 1 to 3.

Swelling in rear legs

Please enter a number from 1 to 3.

Difficulty breathing

Please enter a number from 1 to 3.

Shortness of breath

Please enter a number from 1 to 3.

Has had pneumonia more than once

Please enter a number from 1 to 3.

Group Four Total

Group Four Percentage

Group Five – Hepatic, Gall Bladder

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

On meds over long time

Please enter a number from 1 to 3.

Stool watery or diarrhea

Please enter a number from 1 to 3.

Appears bloated

Please enter a number from 1 to 3.

Lethargic, depressed, restless

Please enter a number from 1 to 3.

Increased shedding

Please enter a number from 1 to 3.

Red eyes or ears

Please enter a number from 1 to 3.

Sporadic vomit/diarrhea

Please enter a number from 1 to 3.

General itchiness

Please enter a number from 1 to 3.

Allergies

Please enter a number from 1 to 3.

Seizures, tremors

Please enter a number from 1 to 3.

Change in appetite

Please enter a number from 1 to 3.

Frequent anesthetics

Please enter a number from 1 to 3.

Food sensitivities

Please enter a number from 1 to 3.

Anal Sac problems, Scooting

Please enter a number from 1 to 3.

Licks or chews at feet or anus

Please enter a number from 1 to 3.

Red tummy

Please enter a number from 1 to 3.

Stands with back arched

Please enter a number from 1 to 3.

Elevated cholesterol, triglycerides

Please enter a number from 1 to 3.

Elevated liver enzymes, lipase

Please enter a number from 1 to 3.

Itching or squinting eyes

Please enter a number from 1 to 3.

Ocular discharge

Please enter a number from 1 to 3.

Rubs at ears or face

Please enter a number from 1 to 3.

Crusty lip sores

Please enter a number from 1 to 3.

Gas

Please enter a number from 1 to 3.

Group Five Total

Group Five Percentage

Group Six – Digestion

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Vomits after fatty meal

Please enter a number from 1 to 3.

Halitosis

Please enter a number from 1 to 3.

Pale-colored stool

Please enter a number from 1 to 3.

Stomach distress common

Please enter a number from 1 to 3.

History of pancreatitis

Please enter a number from 1 to 3.

Recurrent diarrhea

Please enter a number from 1 to 3.

Rancid odor to stool

Please enter a number from 1 to 3.

Belches, regurgitation

Please enter a number from 1 to 3.

Intermittent vomiting

Please enter a number from 1 to 3.

Excessive or chronic eye drainage

Please enter a number from 1 to 3.

Poor coat

Please enter a number from 1 to 3.

Recent intestinal parasites

Please enter a number from 1 to 3.

Group Six Total

Group Six Percentage

Group Seven A – Thyroid Glands

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Increased shedding

Please enter a number from 1 to 3.

Thinning, sparse coat, bald spots

Please enter a number from 1 to 3.

Warts

Please enter a number from 1 to 3.

Dry, scaly skin

Please enter a number from 1 to 3.

Obese or can’t lose weight

Please enter a number from 1 to 3.

Oily, greasy coat, body odor

Please enter a number from 1 to 3.

Weak pulse

Please enter a number from 1 to 3.

Elevated blood cholesterol

Please enter a number from 1 to 3.

Fatty tumors

Please enter a number from 1 to 3.

Stiff gait

Please enter a number from 1 to 3.

Depression, mentally dull

Please enter a number from 1 to 3.

Exercise intolerant

Please enter a number from 1 to 3.

Back/neck problems

Please enter a number from 1 to 3.

Increased pigment to skin

Please enter a number from 1 to 3.

Weak knee ligaments

Please enter a number from 1 to 3.

Group Seven A Total

Group Seven A Percentage

Group Seven B – Pituitary Gland

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Failing memory

Please enter a number from 1 to 3.

Abnormal thirst

Please enter a number from 1 to 3.

Weight gain around rear end, fat pads

Please enter a number from 1 to 3.

Neutered male retains sexual activity

Please enter a number from 1 to 3.

Abnormal heat cycles of intact females

Please enter a number from 1 to 3.

Pigment spots to skin

Please enter a number from 1 to 3.

Group Seven B Total

Group Seven B Percentage

Group Seven C – Adrenal Glands, Hyperactive

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Excessive water consumption

Please enter a number from 1 to 3.

Increased urination

Please enter a number from 1 to 3.

Thin skin

Please enter a number from 1 to 3.

Decline in arthritic symptoms

Please enter a number from 1 to 3.

Panting more than used to, excessive

Please enter a number from 1 to 3.

Lethargic

Please enter a number from 1 to 3.

Pacing

Please enter a number from 1 to 3.

Weak knees

Please enter a number from 1 to 3.

Muscles seem weak

Please enter a number from 1 to 3.

Distended abdomen

Please enter a number from 1 to 3.

Change in behavior

Please enter a number from 1 to 3.

Thinning fur

Please enter a number from 1 to 3.

Group Seven C Total

Group Seven C Percentage

Group Seven D – Adrenal Glands, Hypoactive

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Weakness

Please enter a number from 1 to 3.

Depression

Please enter a number from 1 to 3.

Slow heart

Please enter a number from 1 to 3.

Weak pulse

Please enter a number from 1 to 3.

Intermittent anorexia

Please enter a number from 1 to 3.

Collapse

Please enter a number from 1 to 3.

Group Seven D Total

Group Seven D Percentage

Group Eight – Musculoskeletal (Calcium / Magnesium Metabolism)

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Older dog

Please enter a number from 1 to 3.

History of any joint surgery

Please enter a number from 1 to 3.

Back or disc problems

Please enter a number from 1 to 3.

Bone spurs or enlarged joints

Please enter a number from 1 to 3.

Difficulty getting up and down

Please enter a number from 1 to 3.

Arthritic, degenerative joint disease

Please enter a number from 1 to 3.

Has had ligaments damaged

Please enter a number from 1 to 3.

Rapidly accumulates tarter on teeth

Please enter a number from 1 to 3.

Losing muscle tone in legs or back

Please enter a number from 1 to 3.

Healing fracture in body

Please enter a number from 1 to 3.

Suffering from a sprain or strain

Please enter a number from 1 to 3.

Difficulty supporting weight

Please enter a number from 1 to 3.

Group Eight Total

Group Eight Percentage

Group Nine – Renal

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Abnormal or frequent urination

Please enter a number from 1 to 3.

History of bladder infections

Please enter a number from 1 to 3.

Reduced renal function

Please enter a number from 1 to 3.

High blood calcium or phosphorus

Please enter a number from 1 to 3.

History of bladder stones

Please enter a number from 1 to 3.

Licking at penis or vulva

Please enter a number from 1 to 3.

Cries when urinating

Please enter a number from 1 to 3.

Elevated vitamin D

Please enter a number from 1 to 3.

Leaking urine

Wants to go outside more often

Please enter a number from 1 to 3.

Prostate enlarged

Please enter a number from 1 to 3.

14 or more years old

Please enter a number from 1 to 3.

Group Nine Total

Group Nine Percentage

Group Ten – Immune

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Increased shedding

Please enter a number from 1 to 3.

Red bumps to skin

Please enter a number from 1 to 3.

Scabs, sores, or crusts to skin

Please enter a number from 1 to 3.

Dandruff, flaking

Please enter a number from 1 to 3.

Has had cancer

Please enter a number from 1 to 3.

Skin crawls

Please enter a number from 1 to 3.

Poor fur quality

Please enter a number from 1 to 3.

Body or ear odor

Please enter a number from 1 to 3.

Shakes head or rubs at ears

Please enter a number from 1 to 3.

Experienced a vaccine reaction

Please enter a number from 1 to 3.

Frequent infections

Please enter a number from 1 to 3.

Odor that returns shortly after bath

Please enter a number from 1 to 3.

Moist or heat under front/rear legs

Please enter a number from 1 to 3.

Changed skin appearance

Please enter a number from 1 to 3.

Severe dental infection

Please enter a number from 1 to 3.

Group Ten Total

Group Ten Percentage

Group Eleven – Pain

Put a number in the box in front of the symptom only that applies to your dog. 1 = mild, 2 = moderate, 3 = severe. LEAVE BLANK if it does not apply.

Lameness, abnormal gait

Please enter a number from 1 to 3.

Withdrawn, hiding

Please enter a number from 1 to 3.

Reluctant to move

Please enter a number from 1 to 3.

Dislike or intolerance of handling

Please enter a number from 1 to 3.

Overall activity less than normal

Please enter a number from 1 to 3.

Looks depressed

Please enter a number from 1 to 3.

Hanging or tucked tail

Please enter a number from 1 to 3.

Decreased appetite

Please enter a number from 1 to 3.

Recent surgery, dental infection

Please enter a number from 1 to 3.

Playing less

Please enter a number from 1 to 3.

Less interested in going for a walk

Please enter a number from 1 to 3.

Change in mood, grumpy

Please enter a number from 1 to 3.

Hunched back or sway back

Please enter a number from 1 to 3.

Groaning, moaning, grunting

Please enter a number from 1 to 3.

Weeping, red, cloudy or squinting eyes

Please enter a number from 1 to 3.

Heavy panting, increased heart rate

Please enter a number from 1 to 3.

Change in appetite & type of food willing to eat

Please enter a number from 1 to 3.

Licking inanimate objects (can often be a sign of intestinal pain)

Please enter a number from 1 to 3.

Wobbly

Please enter a number from 1 to 3.

Shifting weight off area of body

Please enter a number from 1 to 3.

Licking excessively an area of the body

Please enter a number from 1 to 3.

Restlessness; pacing

Please enter a number from 1 to 3.

Lower or tilted head or ears

Please enter a number from 1 to 3.

Temperamental, yelp or growl at others

Please enter a number from 1 to 3.

Change in toileting habits

Please enter a number from 1 to 3.

Group Eleven Total

Group Eleven Percentage

Totals

Final Total