EXOTIC COMPANION MAMMAL HISTORY FORM
Please help us get to know your pet
Date
*
-
Month
-
Day
Year
Date
Pet Details
Name or ID
*
Species
*
DOB / Age
*
Sex
*
Male
Male Neutered
Female
Spayed Female
Unknown
Does your pet have a microchip?
*
Yes
No
How long have you had this animal?
From where did you obtain this animal?
Is your animal vaccinated?
*
Yes
No
List vaccines and dates given
*
Do you have any other pets in the household?
*
Yes
No
When was the last animal added to your household?
Do people who have contact with the animal have symptoms similar to the animal?
*
Yes
No
Reason for visit today
What is the primary complaint or what signs have you noticed?
*
How long have these problems been present?
*
What health problems has your pet had previously?
Has your pet received any treatment in the last 30 days?
*
Yes
No
Please give details (what was used, dosage, how often, duration)
Has your pet been seen by another veterinarian?
*
Yes
No
Please provide details
*
Have you noticed any change in your pet’s behavior?
*
Yes
No
Please provide details
*
Have any animals or people in the house become sick in the last 30 days?
*
Yes
No
Diet
How often do you feed your animal?
*
Indicate which foods are eaten and in what amounts
Pellets or other formulated diet
Fruits and/or vegetables
Hay
Meat or meat products
Treats
Other
Pellets Brand?
Pellets Amount?
Fruits Type?
Fruits Amount?
Hay Type?
Hay Amount?
Meat Type?
Meat Amount/Size?
Treat Brand?
Treat Amount?
Do you use any nutritional supplements (calcium, multivitamin, etc)?
*
Yes
No
What, how much, and how often?
Any recently added food or dietary changes?
*
Yes
No
Please give details
*
What water supply do you provide?
*
Tap
Well
Bottled
Other
How is water provided?
*
Bowl
Dripper bottle
How often is it changed?
Do you use any water supplements?
*
Yes
No
Please give details
*
Have you noticed any changes in eating or drinking behavior?
*
Yes
No
Please give details
*
Have you noticed any changes in droppings (fecal material, urine, and/or urates)?
Please give details
Cage Environment
Where is the cage located?
*
Inside
Outside
Please give details
What is the cage made of?
Cage Dimensions?
What kind of bedding or substrate is used?
What decor or furnishings are present?
What percentage of time does your pet spend inside its cage?
Is your pet supervised when out of the cage?
*
Yes
No
Please give details
Are bathing/soaking facilities provided?
Yes
No
Please give details
Does anyone in the household smoke?
Yes
No
Do you use any aerosolized products?
Yes
No
How often is the cage cleaned?
What kind of soap/disinfectant do you use?
Have there been any changes in the pet’s environment in the last 3 months?
Yes
No
Please give details
Please list any other avian or exotic pets
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