Rabbit Health Questionnaire Form "*" indicates required fields Date* MM slash DD slash YYYY Name* First Last PronounsAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneEmail Emergency Contact(other than immediate family)PhonePatientPet's NameAge or BirthdayBreedColourSex Male Female Unknown Neutered Spayed How long have you had your rabbit?From where did you acquire your rabbit?Is your rabbit vaccinated for RHDV? Yes No If known, list vaccine and date(s) givenVaccineDate(s) Given Add RemoveDo you have other pet(s) in the household? Yes No If yes, list the number of pets and species*SpeciesNumber of Pets Add RemoveHousingIs your rabbit housed in a Cage Ex-pen Room Free Roam Outdoor Hutch What are the dimensions of their enclosure?What materials do you use for flooring and bedding?Where does your rabbit urinate and defecate? Litterbox Self-selected corner of enclosure Anywhere they please Other What do you provide for litter?How often do you clean your rabbit’s cage, and/or change the litter?What cleaning agents are used?How much time do they get to explore outside their area?Is your rabbit exposed to: Fireplaces Burning fuels Smokers Aerosols (plug ins, candles, incense) Scented products (laundry soap, perfumes) Do you provide UVB lighting for your rabbit? Yes No If yes, what type of light is used and how often is it changed?*Does your rabbit go outside? Yes, supervised Yes, unsupervised No If yes, please provide details*Does your rabbit dig, burrow or chew on things around the home? Yes No What types of enrichment toys do you provide your rabbit?DietHave there been any recent changes/additions to your rabbit’s diet? Yes No If yes, please provide details*Does your rabbit drink from a Sipper bottle Bowl Other Other*What foraging opportunities do you provide for your rabbit during mealtimes? Please list all food items your rabbit consumes, as well as quantities given: Hay (list all types fed)Alternate fiber sources (eg, bark, forage)Fresh vegetablesPellets (brand)FruitsTreatsOtherHealth & Fitness:Does your rabbit allow you to perform any of the following grooming procedures: (check all that apply) Trim nails Brush fur Clean ears Clean scent glands Other Other*Has your rabbit had any previous health issues? Yes No If yes, please provide further details*Is your rabbit currently on ANY supplement or medication (incl. glucosamine, digestive cookies, probiotics, etc)? Yes No If yes, please indicate how often and amountsMedication/SupplementFrequencyAmounts Add RemoveHave you noticed any changes in water consumption? No change Increased drinking Decreased drinking Have you noticed any of the following changes in eating habits: (check all that apply) Changes in eating habits Difficulty eating Slower to eat certain foods Grinding their teeth Changes in food preferences Dropping foods Drooling Have you noticed any of the following changes to their urine or fecal production: (check all that apply) Increased urination Change in litterbox habits Liquid fecal matter Decreased urination Wet, clumped fecal matter Fecal balls strung with fur Urine spraying Reduction in size of fecal balls Variation in size and/or shape of fecal balls Have you noticed any of the following symptoms in your rabbit: (check all that apply) Scratching Runny eyes/nose Lameness or change in mobility Fainting, collapse or shortness of breath Flakey skin Sneezing and/or coughing Changes in behaviour Lumps or bumps Abnormal vocalization Increased thumping Do you have any specific questions or concerns?EmailThis field is for validation purposes and should be left unchanged.