Rabbit Health Questionnaire Form Owner’s Name Date MM slash DD slash YYYY 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 rabbit What type of food do you feed your rabbit and how much do you feed? Timothy hay % of dietAlfalfa hay % of dietTimothy pellets cup/dayAlfalfa pellets cup/dayFruits & Vegetables cup/dayOther Does your rabbit drink from a bottle or a bowl? Does your rabbit use a litter box? Yes No What do you use for litter? How often do you clean your rabbit’s cage? What do you use for bedding? How much time does your rabbit spend in its cage or does he/she have their own room to run in? Does your rabbit go outside? How much time is spent outside? Do you groom your rabbit (i.e. trim nails, brush fur)? How often? Does your rabbit have any contact with other pets /animals inside or outside of the home? Yes No If yes, please describeHas your rabbit been to a veterinar ian before? Yes No If yes, when/where? Does your rabbit chew on things that he/she should not chew on? Has your rabbit ever had their teeth trimmed? Yes No If yes, when/where? Has your rabbit had any wet, clumped fecal matter? How often do you notice it? Have you noticed any of the following: Scratching Flakey skin Teeth grinding Lumps or bumps Runny eyes/nose Changes in urine or fecal production Sneezing and/or coughing Changes in behaviour Changes in eating and or drinking habits Size of fecal balls Do you have any other questions or concerns? NameThis field is for validation purposes and should be left unchanged.
