Exotic Patient History Form

Full Name*

Email*

Phone*

Pet's Name*

Species*

Gender*

Age/Date of Birth*

How long have you had your pet?*

How did you obtain your pet (pet store, breeder, previous owner, rescue, other)*

Appointment Date/Time*

Appointment Type *

Reason for visit *

Please list all the current medications and supplements you give your pet*

Do you need any refills on the medications you listed?If so, please list the medication name, dosage, and quantity needed.*

Where is your pet housed for the majority of the day? (Caged, Free Roam, Outdoors, Other)*

Describe your pet’s environment/enclosure (type, size, toys, substrate, furnishings, etc.)*

Is your pet housed with any other animals? If yes, please describe species, breed, gender*

Is your pet supervised when outside of their enclosure?

What do you feed your pet? (Hay, Pellets, Fruits, Vegetables) Please provide brands, quantity and frequency.*

Water Source (tap, filtered, bottled, other)*

Do you have any concerns about your pet’s behavior at home?*

Does your pet chew on carpet or any other objects/materials when outside of their enclosure?*

Is there anything else you would like to address during your visit?*

Past Medical History (including diseases, conditions, and prior surgical procedures) Has your pet been seen by any other veterinarian for any of the current problems? If yes, please list clinic.*