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Exotic Companion Mammal Patient History
Client Name:
First
Last
Pet Name
*
Phone Number:
*
Species/Breed
*
Sex of patient
*
Intact Male
Neutered Male
Intact Female
Spayed Female
Unknown
Color
Age
*
Is your pet microchiped?
*
Yes
No
Unknown
Where did you acquire you pet?
Is you pet vaccinated (ferret and rabbits only)?
Distemper
Rabies
Pasterurella
Unknown
Date vaccines given
Date Format: MM slash DD slash YYYY
Have you or your pet been in contact with any other small mammals within the last 30 days?
Yes
No
Unknown
Diet
How often do you feed your pet?
*
How often is the food and water changed?
Indicate what type of food is eaten.
Pellets
Hay
Seed mixtures
Kibble
Insect
Fruits and vegetables
Treats
Other
Please give details on brand and amount given for each type of food that is eaten
Any recently added food or dietary changes?
Yes
No
Please give details.
What vitamins or supplements do you give you pet?
What water supply do you provide?
Tap
Well
Bottled
Other
How often are the food dishes washed?
What type of soap/disinfectant is used?
Have you noticed any changes in eating or drinking behavior?
Yes
No
Please give details.
Have you noticed any change in droppings?
Yes
No
Please give details.
Cage Environment
Is this pet confined to a cage or an enclosure?
Yes
No
Please give details on the cage/enclosure
What is the cage/enclosure size?
What is used in the bottom of the cage/enclosure?
What furnishings are present in the cage/enclosure?
Litter Box
Bed
Hide Box
Toys
Other
How often is the cage cleaned?
What type of soap/disinfectant is used?
Have there been any changes in your pet's environment in the last 3 months?
Yes
No
Please give details on the changes
Reason for Appointment
What is the primary complaint or what signs have you noticed?
How long have these problems been present?
What health problems has your pet had previously?
Has your pet seen another veterinarian or received any treatment?
Yes
No
Have you noticed any change in your pet's behavior?
Yes
No
Please provide details
Have there been any pets in contact with this one that have died within the last month?
Yes
No
Please provide details
Has this pet been sick at any other time during the last 12 months?
Yes
No
Please provide details
Please list any other avian or exotic pets
List Name, Age, Breed & Sex
Home
New Clients
What to Expect
Take A Tour
Make an Appointment
About
Our Hospital
Team
Locations & Hours
Testimonials
FAQs
Payment Information
Services
Additional Services
Alternative and Complementary Therapy
Anesthesia and Patient Monitoring
Breeding Services
Exotic Pet Medicine and Surgery
Health Screening Tests
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Pet Health
Illustrated Articles
How-To Videos
Pet Health Checker
News
FAQs
Links
MyPetED
American Veterinary Medical Association
American Animal Hospital Association
Book Appointment
Client Forms
Curbside Form
New Client Information Form
New Pet Information Form
Reptile/Amphibian Patient History Form
Photo Release Form
Exotic Companion Mammal Patient History Form
Owner Questionnaire
Pet Portal
Online Store