Ervets4pets.com - Small Exotic Mammal History Form

Small Exotic Mammal History Form
Patient/Owner Information
Patient name*
Date*

MonthDayYear
Date
Owner name*
Presenting Complaint
What is going on?*
When did it start?*
Has it been getting worse?*
Current Appetite?*

NormalIncreasedDecreasedAnorexic
Stools
Color
Consistency
Amount
Frequency
Urination
Color
Amount
Frequency
Straining or vocalization?

YesNo
Have you noticed the following symptoms?*

Behavior ChangeLethargy/Decreased ActivityAbnormal UrinationNasal or Ocular DischargeCoughingScratchingHair Loss/AbnormalitiesSkine SoresLamenessVocalizationLoss of BalanceWeaknessVomiting/RegurgitationChange in StoolsChange in AppetiteWeight ChangeSneezingIncreasing Breathing Rate/EffortItchingExcessive SheddingMasses or LumpsHead TiltInactivity/HidingNoneOther
Describe Any Other Changes*
Have there been any pets in contact with this one that have died within the last month?

YesNo
If Yes, Explain*
Has this pet been sick at any other time during the last 12 months?*

YesNo
If so, by whom was it seen?*
Has this pet been given any medications or supplements in the past 7 days?*

YesNo
If yes, which ones?*
Does this pet have any medical conditions?*

YesNo
Please describe*
Does this pet take any medications regularly?*

YesNo
Please list medications and dosing*
Patient Information
How long have you owned this pet?*
Is this your first small mammal?*
Where did you get your pet? (Breeder, Private, Home, Pet Store, Surrendered)*
Cage information
Cage description (Size, Shape, Bar Spacing)*
Substrate (Care Fresh, Yesterday’s News, Wood Shavings, Harwood Chips, Newspaper, Other)*
Cage accessories (Sleeping Box, Climbing Toys, Shelves, Other)*
Cage toys (Exercise Wheel, Play Tubes, Chew Toys, Other)*
Housing information
What is the temperature of your pet’s environment during the day?*
What is the temperature of your pet’s environment at night?*
How often is your pet’s enclosure cleaned and with what products?*
Is this pet housed in the same cage with another animal?*

YesNo
How many other animals are housed with your pet?*
Species of cage mate(s)*
Age of cage mate(s)*
Please list all
Sex of cage mate(s)*
Please list all
Are there any other pets in the house?*

YesNo
What kind of animals are present in the home?*
Is your pet described in this form exposed to these animals?*
Have there been any changes in the household? (New People, New Pets, Remodeling, Etc.)*
How much time does your pet get out of its cage per day?*
Is your pet supervised when out of its cage?*
Does anyone smoke in the house?*
Is your pet being seen for vomiting and/or diarrhea?*

YesNo
Diet
What percentage of food does your pet eat?
Pellets %*
Seed %*
Table Food %*
Other %*
Types and percentage of table food your pet eats
Fruits %*
Vegetables %*
Other %*
What Brand of food do you feed?*
What treats are given?*
How often?*
Are there any recent diet changes?*

YesNo
Please describe*
Do you give supplements? (Vitamin C, Calcium)

YesNo
If so, what kind and how frequently?*
How is water offered?*

BottleBowlCage CupOther
How often is water changed?*
How often are food dishes washed?*
What type of soap/disinfectant is used?*
Should be Empty:

Small Exotic Mammal History Form

Patient/Owner Information

Presenting Complaint

Stools

Urination

Patient Information

Cage information

Housing information

Diet

What percentage of food does your pet eat?

Types and percentage of table food your pet eats