Rabbit & Rodent History Form
An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information. Please check the appropriate boxes or use the spaces provided.
Your Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Pet's Name
Gender
Male
Female
Unknown
Spayed/Neutered
Yes
No
Date of birth
Pet's Age
Date acquired and source (pet store, breeder, previous owner)
Number of previous owners (other than the breeder, store)
What states/countries has your pet lived in?
Is the animal kept
Indoors
Outdoors
Both at times
Describe the cage enclosure (type, size, objects in the cage including dust baths, toys, etc...)
What material is used to line the bottom of the cage/litter pan
Is the animal kept in a cage with other animals
Yes
No
If you answered yes to the previous question, how many cage-mates are there, what are their sexes and are they spayed/neutered
Please list all other household pets
Have there been any new additions within the past six months?
Yes
No
If yes, please specify
How much time does your pet spend outside of the cage
Is your pet supervised when out of the cage?
At all times
No
Sometimes
Does your pet chew on carpet or other objects/materials when outside of the cage? If so please describe
List recent changes in the environment if any
What amount of your pet's diet consists of the following?
please describe what the animal actually eats, not what is offered
Amount of hay (timothy, alfalfa, etc...)
Amount of pellets (timothy, alfalfa, etc...)
Amount of seeds (type/brand)
Amount of vegetables (types)
Amount of fruits (types)
Other (amount/types)
How often do you change your pet's food
What (if any) treats do you give your pet (brand and amount)
Is their food or water supplemented with vitamins
Yes
No
If so, brand and frequency
Do you supplement your pet with any other vitamins
Yes
No
If so, brand and frequency
Please describe any recent change to your pet's diet
Has the pet been bred before?
No
Yes
If yes how many times
When was it last bred
What was the size of all previous litters
Was the litter healthy
Do you plan on breeding this pet in the future
Yes
No
Is your pet here for
A well pet check-up (no major health concerns) you may skip to the previous conditions section
A sick/unhealthy evaluation with health concerns
If your pet is sick, please describe the signs and how long your pet has been showing these signs
Is your pet's general activity level
Normal
Decreased
Increased
Is your pet's appetite
Normal
Decreased
Increased
Have you noticed any of the following
Weight loss
Weight gain
Discharge from the eyes or nose
Increased breathing rate or effort
A change in droppings
An increased or decreased thirst
Weakness
Has your pet had any previous conditions, operations or problems (including dental or gastrointestinal problems)?
Yes
No
If yes please describe
Is your pet currently on any medications
Yes
No
If yes please describe
Has your pet been on on any medications recently
Yes
No
If yes please describe
Is there anything else you would like done today? (Nail trim, have questions, etc...)
Submit
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