Small Mammal Patient History Form Small Mammal Patient History Form Owner's Name * Owner's Name First First Last Last Email * Date * Pet Name * Species/Breed * Age / D.O.B * Pet’s Color * Sex * Male Female Unsure Is your pet spayed or neutered? * Yes No Unknown How long have you owned this pet? * Where did you acquire your pet? * Is this pet confined to a cage or enclosure? * What kind of cage do you use? * What is used in the bottom of the cage? * What Brand of food do you feed? * What Vegetables/fruit do you offer? * How often do you offer Vegetables? * How often do you offer Fruit? * What supplements and/or treats do you give your pet? * Do you provide hay for your pet (rabbit, guinea pig, chinchilla)? * Yes No Do you give your pet tap or purified water? * How often is food and water changed? * How often are the food dishes washed? * What type of soap/disinfectant is used? * Have there been any pets in contact with this one that have died within the last month? * Yes No If yes, explain Has this pet been sick at any other time during the last 12 months? * Yes No Has this pet been to see another veterinarian in the past 12 months? * Yes No If so, whom? Has this pet been given any medications or supplements in the past 3 months? * Yes No If yes, which ones? Does your pet have a microchip? * Yes No Unsure LIST OTHER AVIAN OR EXOTIC BREEDS YOU HAVE AT HOME Pet’s Name Breed Age Sex plus1 Add another pet minus1 Remove a pet Submit If you are human, leave this field blank.
