• 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 
  • Diet and Enrichment Information

  • 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.
  • 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 offered
    Producer/DistributorStateType of HayAmountFrequency per dayDays per week 
  • Please 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 
  • List other food items offered for enrichment purposes (e training, enrichment, educational programs, etc.).
    Food itemPreparationAmount/Weight (grams)Freq per dayMonths offered 
  • Water and Supplementation Information

  • ManufacturerTypeDoseFrequency