Patient History Form

Patient History Form

Date
Name*
Phone*
Email*
Instructions: An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information. Please check the appropriate boxes or use the spaces provided. Thank you!

Patient Information

Species
Gender
Spayed/Neutered
Date of Birth
Date acquired and source (pet store, breeder, previous owner)
Number of previous owners (other than breeder, store)
What states and countries has your pet lived in?

Environment

What material is used to line the bottom of the cage/litter pan?
Is the animal kept in a cage with other animals?
If you answered yes to the previous question -
How many cage-mates are there?
What sex are the cage-mates?
Please list all other pets in the household
Have there been any new pets (within the past six months) placed in this animal’s cage?
How much time does your pet spend outside of the cage?
Is your pet supervised when it is out of the cage?
Does your pet chew on carpet or other objects/materials when outside of the cage?
List recent changes in the environment, if any:

Diet

What amount of your pet’s diet consists of the following (please describe what the animal actually eats, not what is offered)

Amount of Hay (Timothy, Alfalfa, etc.)
Amount of Pellets (Timothy, Alfalfa, etc.)
Amount of Seeds (type/brand)
Amount of Vegetables (types)
Amount of Fruits (types)
Other
Amount and type
How often do you change your pet’s food?
What (if any) treats do you give your pet (brand and amount)?
Do you supplement your pet with any vitamins?
Is the food or water supplemented with vitamins?
Brand and frequency?

Reproductive

Has this pet been bred before? If yes, how many times?
When was it last bred?
Do you plan on breeding this pet in the future?
Is your pet here for:
If your pet is sick, please describe the signs and how long your pet has been showing these signs:
Is your pet’s activity level:
Is your pet’s appetite:
Have you noticed any of the following?

Previous Conditions

Miscellaneous

Is your pet currently on any medications?
Has your pet been on any medications recently? If yes, please list them.
Is there anything else you would like done today?
Nail trim
Have questions about
Other
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