Small Animal History Form
Please fill out this form completely prior to your appointment. If your pet lives in a group the well-being and history of the rest of the group is important information as well.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Date of Appointment
*
-
Month
-
Day
Year
Date
Patient Name
*
Patient Age or Date of Birth
*
Patient Species
*
Rabbit
Hamster
Guinea Pig
Ferret
Rat
Mouse
Reptile
Other
Patient Gender
*
Male
Female
Neutered Male
Spayed Female
Unknown
Is this a new patient to our hospital?
*
Yes
No
How long have you owned this pet?
*
Has this patient been vaccinated?
*
Yes
No
When was the last vaccine given?
*
Has this pet received a Deslorelin (Suprelorin) implant?
*
Yes
No
When was the implant done?
What is the reason for your pet's visit today?
*
Please describe your pet's enclosure, including size and substrate.
*
How often is the enclosure cleaned?
*
Does your pet receive time out of the cage?
*
Yes
No
Does your pet receive time outdoors?
*
Yes
No
Has your pet had contact with wildlife?
*
Yes
No
Does your pet have toys?
*
Yes
No
What types of toys?
What is your pet's diet? Please include brand of food and the amount fed daily? Please include any treats or supplements provided and when they are given.
*
How old is your current supply of food?
*
Does your pett live in a group?
*
Yes
No
How many are present?
Are they all the same gender or mixed?
All Male Group
All Female Group
Mixed Group
Is the group spayed or neutered?
Yes
No
Other
When did you acquire your latest group member?
Do you have a quarantine protocol?
Yes
No
Where did you obtain your pets?
Does your group undergo any routine treatments (example, parasite control)?
Yes
No
Please list all treatments and the last time given.
Are all members of your group vaccinated for distemper?
Yes
No
Are all members of your group vaccinated for rabies?
Yes
No
Are multiple pets showing signs of illness presently?
Yes
No
Do you own any other pets?
*
Yes
No
Please list them and specify if they have contact with today's patient.
Are your other pets dogs?
*
Yes
No
Are they up to date on their distemper and rabies vaccines?
Yes - up to date on both
No - only up to date on rabies
No - only up to date on distemper
No - not vaccinated for either
Submit
Should be Empty: