Date

Your Name

Your Email

Instructions: An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information. Please check the appropriate boxes or use the spaces provided. Thank You.

Patient information

Species

Gender

Male

Female

Unknown

Spayed/ Neutered

Yes

Unknown

Date of birth

Date acquired and source (pet store, breeder and previous owner)

Number of previous owners (other than the breeder or store)

What states and countries has your pet lived in?

Environment

Is the animal kept in doors or outdoors?

Describe the cage enclosure (type, size, objects in the cage, dust baths, toys, etc.)

What material is used to line the bottom of the cage/litter pan?

Is the animal kept in a cage with other animals?

Yes

If you answered yes to the previous question, how many cage-mates are there?

What sex are the cage-mates?

Are the cage-mates spayed/neutered?

Please list all other pets in the household

Have there been any new pets (within the past six months) placed in this animal's cage?

How much time does your pet spend outside of the cage?

Is your pet supervised when it is out of the cage?

At All Times

Sometimes

Does your pet chew on carpet or other objects/materials when outside of the cage?

List recent changes in the environment, if any

Diet

What amount of your pet's diet consist of the following (please describe what animal actually eats,( not what is offered)

Amount of Hay (Timothy, Alfalfa, etc.)

Amount of Pellets (Timothy, Alfalfa, etc.)

Amount of Seeds (type/brand)

Amount of Vegetables (types)

Amount of Fruits (types)

Other

Amount and type

How often do you change your pet's food?

What (if any) treats do you give your pet (brand and amount)?

Do you supplement your pet with any vitamins?

Yes

Is the food or water supplemented with vitamins?

Yes

Brand and frequency?

Please describe any recent change to your pet's diet?

Reproductive

Has this pet been bred before?

Yes

If yes how, many times?

When was it last bred?

What was the size of all previous litter(s)?

Was the litter healthy?

Yes

Do you plan on breeding this pet in the future?

Yes

Is your pet here for a

wellness check-up

or is it sick?

If your pet is sick, please describe the signs and how long your pet has been showing these signs

Is your pet's activity level

normal

decreased

increased

Is your pet's appetite

normal

decreased

increased

Have you noticed any of the following?

Weight loss

Yes

Weight gain

Yes

Discharge from the eyes or nose

Yes

Increased breathing rate or effort

Yes

A change in the droppings

Yes

Increase in thirst

Yes

General weakness

Yes

Please describe

Previous Conditions

Has your pet had any previous conditions, operations or problems (including dental or gastrointestinal problems)?

Yes

Please List

Miscellaneous

Is your pet currently on any medications?

Yes

Please list

Has your pet been on any medications in the past?

Yes

Please list

Is there anything else you would like done today?

Yes

Nail trim, etc.

Do you have any questions or need additional information?

Yes

Please list

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