Small Exotic Mammal History Form
Patient/Owner Information
Patient name
*
Date
*
-
Month
-
Day
Year
Date
Owner name
*
Presenting Complaint
What is going on?
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When did it start?
*
Has it been getting worse?
*
Current Appetite?
*
Normal
Increased
Decreased
Anorexic
Stools
Color
Consistency
Amount
Frequency
Urination
Color
Amount
Frequency
Straining or vocalization?
Yes
No
Have you noticed the following symptoms?
*
Behavior Change
Lethargy/Decreased Activity
Abnormal Urination
Nasal or Ocular Discharge
Coughing
Scratching
Hair Loss/Abnormalities
Skine Sores
Lameness
Vocalization
Loss of Balance
Weakness
Vomiting/Regurgitation
Change in Stools
Change in Appetite
Weight Change
Sneezing
Increasing Breathing Rate/Effort
Itching
Excessive Shedding
Masses or Lumps
Head Tilt
Inactivity/Hiding
None
Other
Describe Any Other Changes
*
Have there been any pets in contact with this one that have died within the last month?
Yes
No
If Yes, Explain
*
Has this pet been sick at any other time during the last 12 months?
*
Yes
No
If so, by whom was it seen?
*
Has this pet been given any medications or supplements in the past 7 days?
*
Yes
No
If yes, which ones?
*
Does this pet have any medical conditions?
*
Yes
No
Please describe
*
Does this pet take any medications regularly?
*
Yes
No
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)
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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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
Diet
What percentage of food does your pet eat?
Pellets %
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Seed %
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Table Food %
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Other %
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Types and percentage of table food your pet eats
Fruits %
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Vegetables %
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Other %
*
What Brand of food do you feed?
*
What treats are given?
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How often?
*
Are there any recent diet changes?
*
Yes
No
Please describe
*
Do you give supplements? (Vitamin C, Calcium)
Yes
No
If so, what kind and how frequently?
*
How is water offered?
*
Bottle
Bowl
Cage Cup
Other
How often is water changed?
*
How often are food dishes washed?
*
What type of soap/disinfectant is used?
*
Submit
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