Individual Questionnaire ZOO/AQUARIUM GENERAL HEALTH and DIET HISTORY FORM: INDIVIDUALDate MM slash DD slash YYYY Facility name:Facility address:Best Contact Information First name: Last name: Position: Email PhonePrimary veterinarian name (if different from above):Veterinarian contact information (phone number, email):Animal InformationCommon name:Genus/species:ID NumberHouse NameAge/ DOBAnimal InformationSex (M/F)Spayed/Neutered (Y/N)Chemical Birth Control (Y/N)Body Weight (kg)Date Body Weight ObtainedReproductively active?: Yes No If yes, season/months greatest activity?Number of successful pregnancies?Number of live births, in total?Current body condition (scale from 1 to 9, where 1 is emaciated, 5 is ideal, and 9 is morbidly obese):How was body condition assessed? How many and which staff members were involved? Please describe.Is this animal housed with any other animals? Yes No If yes, what species and how many?Are animals housed indoors, outdoors, or both? Does it depend on season? Please describe.If sharing exhibit with other animals, do all share a common space together or do they access the space in subgroupings? Please describe.Is this animal being treated for any current and/or historical condition(s) or disease(s)? Yes No If yes, please list diagnosed condition/disease, approximate date of diagnosis, medications.Condition/DiseaseDate DiagnosedMedication Name, Dose, Route, Frequency Diet and Enrichment Information Feeding Strategy Fed together at same time, same feeding location Fed together at the same, separate feeding locations Fed separately, same or different times, 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. 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 NameFormAmount/Weight (grams)Frequency Hay/BrowseList types of hay and browse offeredProducer/DistributorStateType of Hay/BrowseAmountFrequency per dayDays per week Whole Food ItemsPlease provide information on how food items are prepared (whole vs. chopped, cooked vs. raw, live vs. frozen/thawed, etc.)Food itemPreparation*Amount/Weight (grams)FrequencyMonths offered Other Food ItemsList other food items offered for enrichment purposes (e training, enrichment, educational programs, etc.).Food itemPreparationAmount/Weight (grams)Freq per dayMonths 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 animal particularly prefer? Please describe.Are there any food items that the animal do not particularly like and/or refuse? Please describe.Have you made any changes to the diet offered in the last 4 weeks?: Yes No If so, please describe the change madeWater and Supplementation InformationHow is water provided? Please describe (water dish, water bottle, soaking food items, 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:
