Individual Questionnaire ZOO/AQUARIUM GENERAL HEALTH and DIET HISTORY FORM: INDIVIDUALDate Date Format: 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:Animal InformationID NumberHouse NameAge/ DOBAnimal InformationSex (M/F)Spayed/Neutered (Y/N)Chemical Birth Control (Y/N)Reproductively active?:YesNoIf yes, season/months greatest activity?Number of successful pregnancies?Number of live births, in total?Current body condition (scale from 1 to 5, where 1 is emaciated, 3 is ideal, and 5 is obese):How was body condition assessed? How many and which staff members were involved? Please describe. 5, where 1 is emaciated, 3 is ideal, and 5 is obese):Is this animal housed with any other animals?YesNoIf yes, what species and how many?If yes, do animals share a common yard, and if so, do they access the space all together or in subgroupings? Please describe.Is this animal being treated for any current and/or historical condition(s) or disease(s)?YesNoIf yes, please list diagnosed condition/disease, approximate date of diagnosis, medications.Condition/DiseaseDate DiagnosedMedication Name, Dose, Route, Frequency Diet and Enrichment InformationHow are the animals fed? Fed together at same time, same feeding location Fed at same time, separate feeding locations Fed separately, same or different times, separate feeding locationsInstructions for the following questions: Be sure the “Amount” provided is measurable. Always weigh the measured amount of food on a gram scale and provide the total gram weight for each ingredient.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.Describe all brands, product names, amounts, and frequency for ALL commercial foods offered as a part of regular diet.ManufacturerProduct NameFormAmountFrequency List types of hay and browse offeredProducer/DistributorStateType of HayAmountFrequency per dayDays per week List all other food items offered as a part of regular diet, including leafy greens, cut vegetables, fruit, meat, eggs, insects, etc. Please provide information on how the food is prepared (whole vs. chopped, cooked vs. raw, live vs. frozen/thawed, etc.), food item gram weights and measured amounts, frequency offered per day, and days fed per weekFood itemPreparationAmount/Weight (grams)FrequencyMonths offered List other food items offered for enrichment purposes (e.g. training, interactive sessions, educational programs, etc.).Food itemPreparationAmount/Weight (grams)Freq per dayMonths offered Are there any seasonal variations to the diet provided (aside from enrichment items offered)? 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.)NoAre 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 NoIf 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/dayAre any additives put into the water (vitamins, flavors, etc.)?YesNoIf yes, please describe brand/type, quantity, frequency.Are any dietary supplements (vitamins, fatty acids, oils, etc.) given?YesNoIf yes, please describe brand/type, quantity, frequency.ManufacturerTypeDoseFrequency
