Church Ranch Veterinary Center Small Mammal History Form

General History:

Your Email

example@example.com

Your Name

First Name Last Name

Pet Name

First Name Last Name

Sex (please select all that apply):

Male Female - has not given birth to young in the past Female - has given birth to young in the past Neutered/Spayed Not Neutered/Spayed Unknown

If your pet has given birth, please describe:

Is this your first pet of this kind?

Yes No

How did you acquire?

Store Breeder Other (please describe)

How long have you had your pet? (date acquired)

Are there any other animals in the house?

Yes No

Please specify species, age and date acquired:

Are these other animals in direct contact?

Yes No

Please describe type of contact:

Has your pet ever received any vaccines?

Yes No

Please list the type of and date of last given vaccination:

Do you exercise them?

Yes No

Please describe method and frequency:

Do you handle them?

Yes No

Please describe method and frequency:

Has their environment changed recently?

Yes No

Please describe:

Housing:

Location (select all that apply):

Indoors Outdoors Roam Free All of the above

Please describe amount of time spent in each:

Size and type of cage?

Type of bedding?

How often is the cage cleaned? Using what products?

Methods/ frequency of cleaning food and water dishes?

Kept alone? If not, how many others and what species do they live with?

Diet:

What foods are offered, in what amount and total percentage? (ex. 50% hay, 30% greens, etc.)

What foods are eaten, in what amount and total percentages? (i.e. 50% hay, 30% greens, etc.)

Are any vitamins or mineral supplements offered? If so, what types and brands?

Are any treats offered? If so, what type, how many and how often?

Any recent diet changes or new foods added to their diet? If so, please describe.

How is water offered? (i.e. sipper bottle, bowl, dropper, etc.)

Reason for Today's Visit:

What signs have you noticed that prompted today's visit?

How long have you noticed this problem?

What symptoms have you noticed? (Select all that apply):

Coughing Sneezing Vomiting Diarrhea Lameness Scratching

Have they been sick previously?

Yes No

Please describe:

Has any other veterinarian ever seen this animal?

Yes No

Who, when, and why?

Please select all tests below that have been performed previously:

Bloodwork Fecal parasite test skin parasite test Radiographs (x-rays) Other: please describe

Please list all medications that are currently being given:

Any illnesses in other animals or humans in the household?

Yes No

Please describe:

Anything else you would like us to know?