Happy Tails - Exotic Small Mammal History Form

1
A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about you can discuss it in more depth with the veterinary staff during your appointment.
2
Email* This field is required.
example@example.com
3
Animal Details* This field is required.
Name or identification
Common or scientific species name
Date of birth
Age
Please Select
Please Select
Male
Female
Male Neutered
Female Spayed
Unknown
Sex
4
How long have you had this animal?
From where did you obtain this animal?
Please Select
Please Select
Yes
No
Is your animal vaccinated?
5
List vaccines and dates given
6
If a primate, has your animal been tuberculosis (TB) tested?
Yes
No
7
If yes, when?
8
If applicable, do you have a license (DNR/USDA) to own this animal?(Please bring your license with you as a photocopy will be required for the medical record)
Yes
No
9
Do you have any other pets in the household?
Yes
No
10
If so, list the number and the species
11
When was the last animal added to your household?
Has your pet had contact with any other animalsin the last 30 days?
12
Please Select
Please Select
Inside
Outside
Where is the cage located?
Provide details
What percentage of time does you animal spend in the cage?
Please Select
Please Select
Yes
No
Is your animal supervised when out of the cage?
What is the cage made of?
What are the dimensions of the cage?
13
Have there been any changes in the environment in the last 3 months?
Yes
No
14
Give details
15
What décor and furnishings are present?
Please Select
Please Select
Yes
No
Is there ventilation (grills or mesh)?
16
Please give size/details
17
What bedding do you use? Please give details
18
Is your animal litter trained?
Yes
No
19
Do you provide any bathing facilities?
Yes
No
20
Please give details
21
What is your animal’s day and night cycle?
Please Select
Please Select
Yes
No
Are there any smokers in the house?
Please Select
Please Select
Yes
No
Do you use aerosolized substances?
How often is the cage cleaned?
What cleaning/disinfectant agents are used?
22
How often do you feed your animal?
23
Indicate which foods are eaten, and in what amounts (by weight, or approx volume).
Pellets : Brand/Amount     Brand/Amount
Vegetables : Type/Amount     Type/Amount
Treats : Type/Amount     Type/Amount
Hay : Type/Amount     Type/Amount
Fruits : Type/Amount     Type/Amount
Meat or meat products : Type/Amount      Type/Amount
Other : Details    Details
24
Do you use any nutritional supplements?
Yes
No
25
If yes what, how much, and how often
26
Please Select
Please Select
Tap water
Bottled water
Rain/river water
What water supply to you provide?
Please Select
Please Select
Bowl
Dripper system
How is water provided?
How often
How often is the water changed?
27
Do you use any water supplements?
Yes
No
28
Please give details
29
Have you noticed any changes in feeding or drinking behavior?
Yes
No
30
Please give details
31
Have you noticed any changes in the droppings?
Yes
No
32
Please give details
33
What is the primary complaint or what signs you have noticed
34
Has this animal had previous health problems?
Yes
No
35
Please give details
36
Have any other animals or persons in the household had any illness within the last 30 days?
37
Has your animal received any medications in the last 3 months (i.e. heartworm medication, dewormer, flea treatments)
Should be Empty: