• ZOO/AQUARIUM GENERAL HEALTH and DIET HISTORY FORM: INDIVIDUAL

  • Date Format: MM slash DD slash YYYY
  • Animal Information

  • ID NumberHouse NameAge/ DOB
  • Sex (M/F)Spayed/Neutered (Y/N)Chemical Birth Control (Y/N)
  • Condition/DiseaseDate DiagnosedMedication Name, Dose, Route, Frequency 
  • How are the animals fed?
  • Instructions 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.
  • ManufacturerProduct NameFormAmountFrequency 
  • Producer/DistributorStateType of HayAmountFrequency per dayDays per week 
  • Food itemPreparationAmount/Weight (grams)FrequencyMonths offered 
  • Food itemPreparationAmount/Weight (grams)Freq per dayMonths offered 
  • How is water provided? Please describe (water dish, water bottle, soaking food items, etc.)
  • ManufacturerTypeDoseFrequency