MAMMAL HISTORY FORM

MAMMAL FORM

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.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
ANIMAL DETAILS
Name or Identification:*
Common or Scientific Name:*
Date of Birth*
Sex*

MaleFemale
Fixed*

NeuteredSpayedUnknown
How Long Have You Had This Animal?*
From Where Did You Obtain This Animal?*
Is Your Animal Vaccinated?*

YesNo
List Vaccines & Dates Given
Do You Have Other Pets In The Household?*

YesNo
If So, List The Number & Species:
Has Your Pet Had Any Contact With Other Animals In The Last 30 Days?*

YesNo
Please Give Details:
REASON FOR PRESENTATION TODAY
What Is The Primary Complaint Or What Signs Have You Noticed?*
Has This Animal Had Previous Health Problems?*

YesNo
If Yes, Please Give Details
Have Any Other Animals Or Persons In The Household Had Any Illness In There Last 30 Days?*

YesNo
Has Your Pet Received Any Medications In The Last 3 Months? (i.e. Heartworm Medication, Dewormer, Flea Treatments)*

YesNo
If Yes, Please Give Details (What Was Used, Dosage, How Often, Duration)
Please Write Any Other Comments Or Details Of Relevance Below:
DIET
How Often Do You Feed Your Animal?*
Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):
Hay: blanks* . Brand: blanks*. Amount: blank*.
Pellets: blanks* . Brand: blanks*. Amount: blank*.
Vegetables: blanks* . Type: blanks*. Amount: blank*.
Fruits: blanks* . Type: blanks*. Amount: blank*.
Meat (Type & Amount): (Freshly Killed, Frozen/Thawed, OR Live POrey0 blanks* . Amount: blank*.
Treats: blanks* . Brand: blanks*. Amount: blank*.
Other Foods/Details:
What Water Supply Do You Provide?*

Tap WaterBottled WaterRain/River Water
How Is The Water Provided?*

BowlDripper System
How Often?*
How Often Is The Water Changed?*
Do You Use Water Supplements?*

YesNo
Please Give Details:*
Have You Noticed Any Changes In Feeding Or Drinking Behavior?*

YesNo
Please Give Details:*
Have You Noticed Any Changes In Droppings (Fecal Material, Urine and Urates)?*

YesNo
Please Give Details:*
Do You Use Any Nutritional Supplements?*

YesNo
If Yes, What How Much, & How Often?
CAGE ENVIRONMENT
Cage Size (Dimensions):*
Where Is The Cage Located?*

InsideOutside
Please Give Details:*
What Is The Cage Made Of?*
What Decor & Furnishings Are Present?*
Is The Animal Supervised When Out Of The Cage?*

YesNo
What Percentage Of Time Does Your Pet Spend Inside & Outside Of Its Cage?*
Is There Ventilation? (Grills Or Mesh)*

YesNo
Please Give Size/Details*
What Bedding Do You Use?*
Please Give Details*
Is Your Pet Litter Trained?*

YesNo
Are Bathing/Spraying Facilities Provided?*
Please Give Details:*
What Is Your Pet's Day & Night Cycle?*
Have There Been Changes In The Environment In The Last 3 Months?*

YesNo
Please Give Details:*
Does Anyone In The Household Smoke?*

YesNo
Do You Use Any Aerosolized Substances?*

YesNo
How Often Is The Cage Cleaned?*
What Cleaning/Disinfectant Agents Are Used?*
Should be Empty:

MAMMAL FORM

ANIMAL DETAILS

REASON FOR PRESENTATION TODAY

DIET

CAGE ENVIRONMENT