PET RABBIT HEALTH INFORMATION SURVEY
General Information
Please fill out separate forms for each rabbit, living or deceased, that you wish to
include in the study. For those questions requiring a response of several words, begin
typing in the shaded rectangle and the field will expand.
1. Name of rabbit:
2. Date forms are being filled out (m/d/y):
3. Is the rabbit:
living
deceased
4. If living, current situation:
shelter
foster home
permanent home
5. Town, state/province/county, and country of residence:
6. Length of time rabbit has been (or was, if deceased) at current residence:
less than one week
more than a week but less than a month
more than one month but less than 6
more than 6 months but less than a year
a year or more
7. General health of rabbit upon arrival at current (or last) residence:
poor
fair
good
excellent
8. How large is/was rabbit’s primary living space?
under 4 square feet
more than 4 square feet but less than 9
more than 9 square feet but less than 25
more than 25 square feet but less than 36
more than 36 square feet
9. Is/was rabbit’s primary living space
outside
inside
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If inside, is/was rabbit ever allowed outdoors? Yes
10. Rabbit breed
known
unknown
mix, known
mix, unknown
No
(list known breed)
(list best guess)
(list known mix of breeds)
(list best guess as to mix)
Rabbit breed variety (color)
11. Gender:
male
female
If female, has she had:
no litters
1-2 litters
3 or more litters
unknown
12. Spayed/neutered:
yes
If yes, age of rabbit at spay/neuter (in months) if known:
no
unknown
13. Current age (estimated if not known). If deceased, give age at death:
6 months or less
more than 6 months up to 2 years
more than 2 years up to 4 years
more than 4 years up to 6 years
more than 6 years up to 9 years
more than 9 years up to 12 years
12 years or older
14. Current weight of rabbit. If rabbit is deceased, check weight at death.
1 kg (2.2 lbs) or less
more than 1 kg up to 2 kg (4.4 lbs)
more than 2 kg up to 3 kg (6.6 lbs.)
more than 3kg up to 4kg (8.8 lbs.)
over 4kg (8.8 lbs.)
15. If rabbit is deceased, cause of death, if known
cause of death determined by necropsy
cause assumed because of illness and/or symptoms
(If rabbit was euthanized, reason for euthanization:
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16. Diet information. Were/are any of the following included in the rabbit’s diet? (Check
all that apply and list average amount given per day)
alfalfa-based pellets
Amount:
grass-based pellets
Amount:
alfalfa hay
Amount:
grass hay
Amount:
fresh greens
Amount:
other vegetables
Amount:
fruit
Amount:
seeds and/or nuts
Amount:
grains
Amount:
treats (e.g. papaya tablets, bread, crackers, purchased treats)
Amount:
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Specific Health information
Please fill out a separate form for each rabbit, living or deceased, that you are including
in the study.
To the best of your knowledge, did/does the rabbit ever have any of the following
medical diseases/conditions (check all that apply):
1. Eye-related health problem? Yes
If yes, check any of the following that apply:
blind in one or both eyes
cause of blindness, if known
cataracts
conjunctivitis (weepy eye caused by inflammation of conjunctiva)
cyst
dacryocystitis (thick smelly discharge from infection in duct)
corneal ulcers
glaucoma
neoplasia (cancer/tumor)
uveitis (inflammation of pigmented layer of iris)
other (describe)
2. Inner/middle ear infection? Yes
If yes: a) organism(s) present, if identified
b) treatment:
c) duration of treatment:
d) did infection return after treatment? Yes
No
3. EC (Encephatalitozoon cuniculi)? Yes
If yes: a) was diagnosis
confirmed through lab work (e.g. titer)?
presumptive based on signs/symptoms?
b) what signs/symptoms of EC were/are present?
c) how was disease treated?
d) did signs/symptoms improve or resolve with treatment? Yes
e) did signs/symptoms return after successful treatment? Yes
No
No
4. Neoplasia (growths, benign and malignant, i.e. cancerous)? Yes
If yes: a) was growth
benign (surrounded by capsule)
malignant (spreads and may metastasize)
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b) was neoplasm:
thymoma/ thymic lymphoma)
mammary carcinoma
uterine adenocarcinoma
other (name:
)
unknown
c) what parts of body were involved (e.g. skin, organ, blood)
d) what signs/symptoms were present?
e) how was cancer treated?
5. Abscess? Yes
If yes, a) where in body?
b) treatment:
c) duration of treatment
d) was treatment successful? Yes
No
If yes, did abscess recur later? Yes
No
6. Broken/fractured bone? Yes
If yes: a) which bone(s)?
b) how treated?
c) describe any permanent loss of function (e.g. limp, paralysis)
7. Dislocation (luxation) or partial dislocation (subluxation)? Yes
If yes: a) where?
b) how treated?
8. Paralysis? Yes
If yes: a) cause
b) treatment
c) was paralysis:
temporary
permanent
9. Head tilt (wry neck)? Yes
If yes: a) cause:
inner ear infection
EC
other (describe:
undetermined
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b) treatment
c) duration of treatment
d) describe any lasting effects (e.g. permanent head tilt)
10. Fur mites or other mites causing dermatitis? Yes
If yes: a) was diagnosis:
confirmed through cellotape or other test?
presumptive based on fur loss, dandruff, other sign/symptoms?
b) What mite species were present, if identified?
c) What treatment was given?
d) Did signs/symptoms disappear after treatment? Yes
No
e) Did mites return after successful treatment? Yes
No
11. Ear mites? Yes
12. Intestinal coccidiosis? Yes
13. Toxoplasmosis? Yes
14. Tapeworms? Yes
If yes: a) was diagnosis:
presumptive based on symptoms
from examination of fecal sample
post-mortem (after death) diagnosis
b) were tapeworms:
larval form (in liver, abdominal cavity) of Taenia (cysticercosis)
adult tapeworms (in intestines) of Cittotaenia
other species of tapeworm (list):
species unknown
c) signs/symptoms present
d) treatment
15. Pinworms? Yes
16. Raccoon roundworm (Baylisascaris procyonis)? Yes
If yes, was diagnosis:
presumptive based on signs/symptoms and/or contamination of
food or living area by raccoon feces
post-mortem (by examination after death)
17. Myiasis (flystrike – larvae internal or visible on genital area)?
Yes
18. Warbles (flystrike – individual bot fly larvae in large nodules under skin )? Yes
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19. Upper respiratory infection (snuffles/rhinitis)? Yes
If yes: a) causal organism, if known:
b) treatment:
c) duration of treatment:
d) did URI return after treatment? Yes
No
20. Lower respiratory infection (pneumonia)? Yes
If yes: a) causal organism, if known:
b) treatment given:
c) duration of treatment:
d) did pneumonia return after treatment? Yes
No
e) did abscesses develop near heart or lungs? Yes
No
Unknown
21. Other respiratory ailment? Yes
If yes, describe ailment and treatment:
22. Myxomatosis? Yes
If yes, treatment given, if any:
23. Rabbit calicivirus disease? Yes
If yes, signs/symptoms present:
Was diagnosis post-mortem (by examination after death)? Yes
No
24. Vent disease (rabbit syphilis/treponematosis)? Yes
25. Viral wart-like growths (Shope, Fibromatosis (viral fibromas)? Yes
If yes, which? (Check all that apply)
Shope fibroma (horn-like growths)
Papillomas (small wart-like growths on skin)
Oral papillomas (wart-like growths in mouth)
26. Gastrointestinal hypomotility (stasis)? Yes
If yes: a) what signs/symptoms were present?
b) list any predisposing circumstances/conditions present (e.g., diet
change, move, dental issues)
c) treatment:
d) Did rabbit have GI hypomotility (stasis):
once
2-4 times
5 or more times
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27. Acute bloat with obstruction? Yes
If yes: a) treatment:
b) did rabbit survive? Yes
No
28. Impaction of cecum? Yes
If yes: a) treatment given:
b) did condition recur? Yes
No
29. Soft stools? (soft fecal pellets, not cecotrophs) Yes
If yes, do/did soft stools occur after rabbit ate a particular food? Yes
If yes, what food?
No
30. True diarrhea? Yes
If yes, a) cause, if known (e.g. course of antibiotics, coccidiosis, mycotoxins):
b) treatment:
31. Enterotoxemia? Yes
If yes, were signs/symptoms:
local (enteritis with watery brown diarrhea)
systemic (GI stasis, toxic shock, sudden death)
32. Mycotoxicosis (mycotoxin poisoning)? Yes
If yes: a) treatment given:
b) was toxin identified by lab? Yes
If yes, name of toxin:
food toxin was in:
No
33. Intestinal coccidiosis? Yes
34. Urolithiasis (crystals in urinary tract, sludge and/or stones)? Yes
If yes, a) treatment given:
b) a) were any stones present in kidney or bladder? Yes
35. Urinary tract infection? Yes
If yes, a) treatment given:
b) duration of treatment:
c) did infection recur after treatment? Yes
No
No
36. Diabetes? Yes
If yes, was diagnosis confirmed by:
blood glucose test
urine glucose test
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37. Kidney (renal) failure? Yes
If yes, a) was it:
chronic
acute
b) cause of failure, if known:
c) treatment given:
38. Arthritis? Yes
If yes: a) what age was rabbit when diagnosed?
b) treatment given:
c) Describe mobility impairment, if any:
39. Ulcerative pododermatitis (sore hocks)? Yes
If yes: a) what surface is on rabbit’s primary living quarters?
b) treatment given:
c) did condition progress to ulcers/bacterial infection? Yes
40. Malocclusion of incisors? Yes
If yes, were maloccluded teeth removed? Yes
No
No
41. Points on cheek teeth? Yes
If yes: a) age at which points first occurred:
b) how treated:
c) frequency of dental work required to alleviate condition:
42. Facial abscesses? Yes
If yes, how treated?
43. Atherosclerosis (buildup of fatty plaques in arteries)? Yes
If yes, was diagnosis:
presumptive, based on signs/symptoms
definitive, based on results of diagnostic tests/procedures
(if checked, list tests/procedures:
)
post-mortem (examination after death)
44. Arteriosclerosis (hardening/thickening of artery walls)? Yes
If yes, was diagnosis:
presumptive, based on signs/symptoms
definitive, based on results of diagnostic tests/procedures
(if checked, list tests/procedures:
post-mortem (by examination after death)
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45. Stroke? Yes
If yes, was diagnosis:
presumptive, based on signs/symptoms
definitive, based on results of diagnostic tests/procedures
(if checked, list tests/procedures:
)
post-mortem (by examination after death)
46. Cardiomyopathy? Yes
If yes, a) was diagnosis:
presumptive, based on signs/symptoms
definitive, based on results of diagnostic tests/procedures
(if checked, list tests/procedures:
)
post-mortem (by examination after death)
b) how treated:
47. Congestive heart failure? Yes
If yes, a) was diagnosis:
presumptive, based on signs/symptoms
definitive, based on results of diagnostic tests/procedures
(if checked, list tests/procedures:
)
post-mortem (by examination after death)
b) how treated:
48. Hypothermia (loss of body heat)? Yes
If yes, was the hypothermia in conjunction with any of the following:
gastrointestinal hypomotility (stasis)
acute bloat
mycotoxicosis (mycotoxin poisoning)
other (list)
49. Hyperthermia (heat stress)? Yes
If yes, were any of the following factors present:
ambient temperatures in excess of 85˚ F (29˚ C)
high humidity
lack of shade and/or ventilation
lack of adequate drinking water
excessive exercise
50. Other disease(s) not listed above? Yes
If yes, describe in detail, listing signs/symptoms, how diagnosed, and treatment:
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If you would be willing to be contacted for more information on any of the
diseases checked, please give your name and email (or other contact
information):
Return completed form to: antilleanblue2000@yahoo.com
Thank you for your participation and your willingness to help rabbits!
Copyright © 2012 Lucile Moore
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