Exotic Companion Mammal Patient History Form – White Rock Veterinary Hospital in Pflugerville, Texas

Client Name:

First Last

Pet Name*

Phone Number:*

Species/Breed*

Sex of patient*

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

Have you or your pet been in contact with any other small mammals within the last 30 days?

Diet

How often do you feed your pet?*

How often is the food and water changed?

Indicate what type of food is eaten.

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