Delton VH - Guinea Pig Lifestyle Questionnaire

Guinea Pig Lifestyle Questionnaire

Instructions: This form helps us get to know your pet so that we can provide the best level of care. If you have any questions, please don't hesitate to give us a call at 780.475.9225.
DATE

Month Day Year
Date
CLIENT INFORMATION
OWNER'S NAME

First Name Last Name
CO-OWNER'S NAME

First Name Last Name
ADDRESS

Street Address

Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER

Area Code Phone Number
SECONDARY PHONE NUMBER

Area Code Phone Number
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME
AGE/D.O.B
SPECIES/BREED
GENDER
DATE ACQUIRED
SOURCE: Pet Store/Breeder/Other
What is the reason for your pets visit?
Please describe primary concern (if applicable)
ACTIVITY

Please describe the signs and how long your pet has been showing these signs. This includes both sick animals, and those that are here for their full physical/annual or semi-annual appointments:
Activity level - Normal/Decreased/Increased?
Appetite - Normal/Decreased/Increased?
Any changes in droppings? - Yes/No
Discharge from eyes/nose/other? - Yes/No
Weight loss? - Yes/No
Weight gain? - Yes/No
An increase/decrease in thirst? - Yes/No
Weakness? - Yes/No
PREVIOUS CONDITIONS
Have your pet had any previous conditions/operations/problems (including dental or gastrointestinal issues)? If yes, please describe.
Is your pet currently on any medications? If yes, please list the name, dose, and frequency.
Has your pet been on any medication recently? If yes, please list the name, dose, and frequency.
DIET

This section is VERY important. Be as accurate as possible. What amount of your pet's diet consists of the following (please describe what the animal actually eats, not what is offered):
How often do you change your pet's food?
Amount of hay and type (Timothy, Alfalfa, etc.):
Amount of pellets, brand and type (Timothy, Alfalfa, etc.):
Amount of seeds, brand and type:
Amount of vegetables and type:
Amount of fruit and type:
Other:
What (if any) treats do you give your pet (brand and amount)?
Is the food or water supplemented with vitamins? If yes, what brand and frequency?
Please describe any other recent changes to your pet's diet:
Environment
Where is the animal kept? - Indoors/Outdoors
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 yes, how many cage mates are there? What sex are the cage mates? And are the cage mates spayed/neutered?
Please list all other pets in the household:
Have there been any new pets (within the past six months) placed in the animal's cage? If yes, please describe.
How much time does your pet spend outside of the cage?
Is your pet supervised when it is out of the cage? Always/Sometimes/No
Does your pet chew on carpet or other objects/materials when outside of the cage?
Please list changes in the environment, if any:
REPRODUCTIVE: Has this pet been bred before? - Yes/No
Additional comments or questions:
Should be Empty:

CLIENT INFORMATION

PATIENT INFORMATION

ACTIVITY

PREVIOUS CONDITIONS

DIET

Environment