Group Questionnaire ZOO/AQUARIUM GENERAL HEALTH and DIET HISTORY FORM: GROUPDate MM slash DD slash YYYY Facility name:Facility address:Contact Information First name: Last name: Position: Email PhonePrimary veterinarian name (if different from above):Veterinarian contact information (phone number, email):Animal Information * Please click the plus (+) icon to add more animals.Common name:Genus/species:Number of animals housed together:*Current body weight in grams or kilograms. Current body condition on scale from 1 to 9, where 1 is emaciated, 5 is ideal, and 9 is morbidly obese.ID NumberHouse NameSexAgeCurrent Body Weight*Current Body Condition* *Current body weight in grams or kilograms. Current body condition on scale from 1 to 9, where 1 is emaciated, 5 is ideal, and 9 is morbidly obese.Are any of the animals spayed/neutered, on chemical birth control, or reproductively active? Please describe.Enter ID Number:Spayed/Neutered (y/n)Chemical birth control (y/n)Reproductively active (y/n) Are any of the animals being treated for any current and/or historical condition(s) or disease(s)? Yes No If yes, please list animal ID, diagnosed condition/disease, approximate date of diagnosis, medications.Animal IDCondition/DiseaseDate DiagnosedMedication Name, Dose, Route, Freq. Exhibit Information Do animals share a common space (yard, free-flight aviary, pond, etc.), and if so, do they access the space all together or in subgroupings? Please describe.Are animals housed indoors, outdoors, or both? Does it depend on season? Please describe.Diet and Enrichment Information Feeding Strategy Fed together at same time, same feeding location Fed together at the same time, separate feeding locations Instructions for the following questions: The "amount" provided must be measured by weight, as obtained using a gram scale. For each food item, provide the TOTAL weight of each ingredient fed daily. All food items will be assumed to be group fed, even if separate feeding locations, because of the opportunity for cross-over, and consumed in equal amounts by all animals, unless otherwise specified. Possible scenarios to troubleshoot: Unlabeled cup or scoop: First measure the amount held in that cup/scoop - for example, “½ scoop” may actually represent a true 1 cup, as measured. Then weigh the volume of diet item held within that container. Abstract unit of measure (e.g. “one handful”), take one handful of the item and obtain the gram weight of that handful 5 days in a row. If different individuals are doing the feeding, make sure that each individual’s handful is represented. Then calculate the average weight (grams) per handful by summing the gram weights from each of the 5 days, and diving by 5. Provide that average weight as the “Amount” below. Hay/browse: For each type of hay/browse item, use either hook scale or flat platform scale and obtain average weight over 5 days.Commercial FeedsDescribe all brands, product names, amounts, and frequency for ALL commercial foods offered as a part of regular diet.ManufacturerProduct NameFormAmountFrequency Hay/BrowseList types of hay and browse offeredProducer/DistributorStateType of HayAmountFrequencyMonths Offered Whole food itemsList all other food items offered as a part of regular diet, including leafy greens, cut vegetables, fruit, meat, eggs, insects, etc.Food itemPreparation*Amount/Weight (grams)Freq per dayDays per week *Please provide information on how food items are prepared (whole vs. chopped, cooked vs. raw, live vs. frozen/thawed, etc.).Other Food itemsList other food items not already described that are offered enrichment, and/or medication purposesFood itemPreparationAmount/Weight (grams)FrequencyMonths Offered Are there any seasonal variations to the diet provided (aside from enrichment items)? If so, please thoroughly describe.In the last 5 years, have you ever had a nutrient analysis performed by a laboratory on either the whole diet and/or any individual food items (e.g. hay, browse, leafy greens, etc.)? Yes (If yes, please provide copies of analyses.) No Are there any food items that the animals particularly prefer? Please describe.Are there any food items that the animals do not particularly like and/or refuse? Please describe.Which feeding methods are utilized for group feeding (check all that apply)? Bowl fed Items scattered around exhibit Free-choice grazing/browsing Target fed If desired, please further describe.Have you made any changes to the diet offered in the last 4 weeks?: Yes No If so, please describe the change(s) made.Water and Supplement Information Please describe how water is provided (water dish, water bottle, soaking food items, automatic filler etc.).How often is water changed? Daily (1x/day) 2x/day >2x/day Automatic filler Are any additives put into the water (vitamins, flavors, etc.)? Yes No If yes, please describe brand/type, quantity, frequency.Are any dietary supplements (vitamins, fatty acids, oils, etc.) given? Yes No If yes, please describe brand/type, quantity, frequency.ManufacturerTypeDoseFrequency Are salt or trace mineral blocks provided? Yes No If yes, please describe brand, type, and frequency provided:
