Small Mammal Patient History
Name
*
First Name
Last Name
Pet Name
*
Date
*
-
Month
-
Day
Year
Date
Species / Breed
*
Color
*
Age / DOB
*
Actual or Estimate
Sex
*
Female
Male
Unknown
How long have you owned your pet?
*
Where did you acquire your pet?
*
Any previous health concerns?
Does your bird have a microchip?
*
Yes
No
Unknown
Have you or your pet been in contact with any other pets within 30 days?
Yes
No
Any smoke, aerosols, sprays or powders used in the home?
Yes
No
If yes, what kinds?
What type of cage do you use?
Indoor Cage
Outdoor Cage
How long does your pet spend in cage?
How long does your pet spend outside of cage?
Where is the cage located?
Approximate size of cage
What is used in the bottom of the cage?
How often is cage changed / cleaned?
*
Daily
Weekly
Monthly
What type of cleaning chemical is used?
*
What type of toys/furnishings are in the cage?
What brand of food do you feed?
What vegetables or fruit do you offer?
How often?
Does your pet receive any supplements?
*
Yes
No
Type of Supplements?
What type of water does your bird receive?
*
Tap
Purified
Sipper Bottle
Bowl
How often is food or water changed?
How often are the food dishes washed?
What type of soap/disinfectant is used?
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