Delton VH - Rabbit & Guinea Pig Lifestyle Questionnaire

Rabbit and Rodent Lifestyle Questionnaire

Instructions: This form helps us get to know your rabbit / rodent so that we can provide the best level of care. If you have any questions, please don't hesitate to give us a call at 780.475.9225.
DATE

Month Day Year
Date
CLIENT INFORMATION
OWNER'S NAME

First Name Last Name
CO-OWNER'S NAME

First Name Last Name
ADDRESS

Street Address

Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER

Area Code Phone Number
SECONDARY PHONE NUMBER

Area Code Phone Number
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME *
AGE/D.O.B *
SPECIES/BREED *
SEX *
SPAYED / NEUTERED:
DATE ACQUIRED *
SOURCE *
Where is the animal kept? *
Describe the cage enclosure (Type, size, objects in cage, etc.)
What material is used to line the bottom of the cage/litter pan?
Is the animal kept in a cage with other animals? *
How many cage-mates are there?
What sex are the cate-mates?
Are all of the cage-mates spayed/neutered?
Have there been any new pets (within the past 6 onths) placed in this animal's cage?
Is your pet kept near guiniea pigs?
Please list all other pets in your household
How much time does your pet spend outside of the cage?
Is your pet supervised when it is out of the cage?
How much time does your pet spend outdoors? Are they supervised or unsupervised?
Does your pet chew on carpet or other objects/materials when outside of the cage?
List any recent changes in your pet's environment:
DIET

This section is VERY important. Be as accurate as possible. Indicate which foods are eaten and in what amounts each day (by number, weight, or approximate volume).
PELLETS (Timothy, ALfalfa, etc.) | Brand and amount:
SEED MIXTURES | Type, brand and amount:
FRUITS and/or VEGETABLES | Type and amount:
TREATS | Brand and amount:
Do you use any nutritional supplements? Is the food or water supplemented with vitamins?
Please describe the brand, amount, dose, and frequency exactly.
Have there been ANY recent changes to your pet's diet? Please describe:
Reproductive
Has this pet been bred before? If yes, how many times?
When was this pet last bred?
What was the size of all previous litters? Were they healthy?
Do you plan on breeding this pet in the future?
Reason for Visit
What was the main reason for this appointment?
Describe the signs of sickness. Select all that apply:

Pet's activity level is normal Pet's activity level is decreased Pet's activity level is increased Pet's appetite is normal Pet's appetite is decreased Pet's appetite is increased Weight loss Weight gain Discharge from eyes and/or nose A change in droppings Increased thirst Decreased thirst Weakness Sneezing / Coughing Vomiting Diarrhea Scratching Itching Limping Hair loss Seems to be in pain
Description of symptoms and additional comments:
Has your pet had any previous conditions, operations or problems (including dental or gastrointestinal problems?)
Is your pet currently on any medications?
Has your pet been on any medications recently? If yes, please list:
Additional comments or questions:
Should be Empty:

CLIENT INFORMATION

PATIENT INFORMATION

DIET

Reproductive

Reason for Visit