Small Mammal History Form

Please provide the information below as completely as possible. All information is strictly confidential. All fields with an asterisk (*) are required.

Patient Information

Owner's Name*
Pet's Name*
Species*
Age*
Sex*
Male
Neutered Male
Female
Spayed Female
Unknown
Color/Markings*
Specific Identification
Tattoo
Microchip
Other
Describe ID location and Details (if applicable)

Reason for Today's Visit

What signs prompted today's visit?*
How long have you noticed the problem?*
How has the problem changed?*
Worse
Better
Same
Has anything seemed to make the problem worse or better?
Does the problem tend to happen at a certain time of day or time of year?
On a scale of 1 to 10, with 1 being normal and 10 being death, how would you rate your pet's problem?*
Have you noticed any of the following signs?(check all that apply)
Behavior change
Lethargy / change in exercise
Nose or eye discharge
Sneezing
Increased breathing rate / effort
Vomiting / regurgitation
Change in stool quality
Change in urination
Lameness / weakness
Change in thirst
Change in appetite
Change in weight
Scratching
Fur loss
Skin lumps (masses)
If your pet has been sick before, please describe.
If your pet has been seen by another veterinarian, who was that vet?
Please describe any medications your pet is currently taking.
Have you tried any over-the-counter remedies or supplements?
Please describe any laboratory tests that have been performed on your pet previously.
Has any member of your household (human or animal) had an illness in the past month?*
Yes
No

General History

How did you acquire your pet?*:*
Store
Breeder
Other
Please provide any other details on the source.
Approximate date when acquired.*
Approximate age when acquired.*
For ferrets, has your pet been previously vaccinated?
Yes
No
Do you have any other pets?*
Yes
No
If yes, please list other pets and whether they have contact with this pet.
Has your pet had any contact with any other animals (besides those listed) in the past 3 months?*
Yes
No
How does your pet get excercise?*

Housing

Where is this pet kept? (select all that apply)*
Indoors
Outdoors
In a cage
Free in house
Is this pet housed alone?*
Yes
No
If no, please describe cage mates.
If pet is caged, what type / size of cage is used? Describe cage furniture and layout.
What bedding/substrate is used on the bottom of cage? How deep is the substrate? What bedding is used in the litterbox?*
Does your pet's cage flooring include a wire grate? If so, what percentage of the floor is covered by the wire grate?*
How often is the cage cleaned, using what method / products?*
What is the average temperature of your pet's enclosure?*
How do you measure the temperature?
Do you do anything to alter your pet's enclosure temperature from the temperature of the surrounding environment?
Does your pet have hiding places available within its enclosure?
If your pet's environment has changed recently, describe those changes.
Describe any bathing opportunities provided, if any.
How often and for what duration of time is your pet allowed outside of the cage?*
Is your pet supervised at all times when outside of cage?*
Yes
No
Is your pet litter trained?*
Yes
No

Diet

How often is food offered to your pet?*
If your pet is free-fed, how often is the food in the bowl changed?
If pellets are offered, what brand are they?
If seed mix is given, what brand / type?
If vegetables are given, what types and are they frozen, fresh, dehydrated, or in some other form?
If fruits are given, what types and are the frozen, fresh, dehydrated, or in some other form?
If hay is offered, what type is it?
If proteins are offered, list types (insects, fish, cheese, meat) and status (live, frozen, dehydrated).
Please describe any treats that are provided.
If dietary supplements are offered, please describe the type and frequency.
If there have been any recent diet changes or new foods, please describe them.
How is water provided?*
Bowl
Sipper bottle
Other
Which water source is used?*
Tap water
Bottled water
Well water
Rain water
How often is the water changed?*
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