Small Rodent Health Questionnaire Form "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Owner's Name* First Last Pronouns (optional)Date* MM slash DD slash YYYY Address Street Address Address Line 2 City Province / Region 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 rodent?From where did you acquire your rodent?Do you have other pet(s) in the household? Yes No If yes, list the number of pets and species*Species# of pets Add RemoveHousingIs your rodent housed in a: Single level cage Multi level cage Room Other What are the dimensions of their enclosure?What materials do you use for bedding and litter?How deep is the level of bedding provided?Where does your rodent urinate and defecate? Litterbox Self-selected corner of enclosure Anywhere they please Other How often do you clean your rodent’s cage, and/or change the litter?What cleaning agents are used?Do they get to explore outside their area? Yes No If yes please provide details (eg, location, if supervised, time spent)*Is your rodent exposed to: Fireplaces Burning fuels Smokers Aerosols (plug ins, candles, incense) Scented products (laundry soap, perfumes) Do you provide UVB lighting for your rodent? Yes No If yes, what type of light is used and how often is it changed?What types of enrichment toys do you provide your rodent?DietHave there been any recent changes/additions to your rodent’s diet? Yes No If yes, please provide details*Does your rodent drink from a Sipper bottle Bowl Other What foraging opportunities do you provide for your rodent during mealtimes? Please list all food items your rodent consumes, as well as quantities given: Pellets (brand)Fiber sources (eg, hay, bark, forage)Fresh vegetablesFruitsTreatsOtherHealth & FitnessHave you noticed any changes in water consumption? No change Increased drinking Decreased drinking Does your rodent allow you to perform any of the following grooming procedures: (check all that apply) Trim nails Brush fur Bathe Clean ears Other OtherHas your rodent had any previous health issues? Yes No If yes, please provide further detailsIs your rodent currently on ANY supplement or medication (incl. glucosamine, digestive cookies, probiotics, etc)? Yes No If yes, please indicate how often and amountsHave 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 pellets strung with fur Urine spraying Reduction in size of fecal pellets Variation in size and/or shape of fecal pellets Have you noticed any of the following symptoms in your rodent: (check all that apply) Scratching Runny eyes/nose Lameness or change in mobility Flakey skin Sneezing and/or coughing Changes in behaviour Lumps or bumps Abnormal vocalization Fainting, collapse or shortness of breath Do you have any specific questions or concerns?