Chinchilla Health Questionnaire Form Owner’s Name Date Address Postal Code Phone numbers (home) (cell) (work) Email Emerg. Contact(other than immediate family): ph: Pet’s Name Breed Colour Sex Male Female Neutered Spayed Age or Birthday How did you acquire your chinchilla ? What type of food do you feed and how much do you feed Timothy hay % of dietAlfalfa hay % of dietChinchilla Pellets % of dietTreats % of dietFruits & Vegetables cup/day Other Does you chinchilla drink from a bottle or bowl? How often does your chinchilla take a bath? How much time does your chinchilla spend in its cage? How of ten do you clean your chinchilla ’s cage? What do you use for bedding? Do you offer toys for your chinchilla to chew on? Does your chinchilla have exercise opportunities? Does your chinchilla go outside? How much time is spent outside? Does your chinchilla have any contact with other pets/animals inside or outside of your home? If yes, what type of animals? Has your chinchilla been to a veterinarian before? If yes, when/where? Does your chinchilla chew on things that he/she should not chew on? Has your chinchilla ever had his/her teeth trimmed? If yes, when/where? Has your chinchilla had any wet, clumped fecal matter? How often do you notice it? Have you noticed any of the following; Flakey skin Teeth grinding Lumps or bumps Runny eyes/nose Size in fecal balls Sneezing and/or coughing Changes in behaviour Changes in eating and/or drinking habits Changes in urine or fecal production Scratching Do you have any other questions or concerns ? PhoneThis field is for validation purposes and should be left unchanged.