Small Mammal History Form Your Pet’s Information:Name*Common name or species*Date of Birth*Sex*Neuter/Spayed?*NoYesHow long have you had your pet?*From where did you obtain your pet?*Do you have other pets in the household?*YesNoPlease list number and species*Cage DetailsWhere is the cage located?*InsideOutsideWhat are the dimensions of the cage?*What is in the cage set up (décor, toys, ventilation, etc)? Substrate?*How often do you clean the cage and what do you clean it with?*Are there are any smokers in the house?*NoYesDo you use aerosolized substances?*NoYesWhat is your pet’s day and night cycle (hours of sleep)?*What percentage of the time does your pet spend in the cage?*Is your pet supervised when out of the cage?*YesNoHave there been any changes in the environment in the last 3 months?*YesNoIf so, please explain:Diet DetailsHow often do you feed your pet?*Please select which foods are eaten: Pellets Hay Vegetables Fruits Meat products Treats/others Pellets: Type, Brand and amount*Hay: Type, Brand and amount*Vegetables: Type, Brand and amount*Fruits: Type, Brand and amount*Meat products: Type, Brand and amount*Treats/others: Type, Brand and amount*Do you use any nutritional supplements in food or water?*YesNoWhat is it, how much, how often?*Water DetailsWhat water supply do you provide?* City tap water Bottled water Well water How is water provided?*BowlDripper systemHow often is water changed?*Reason for Visit todayWhat is the primary reason why you brought your pet in to see a veterinarian today?*Have you noticed any changes in feeding or drinking behavior?*YesNoPlease give details*Have you noticed any changes in droppings?*YesNoPlease give details*Has your pet had any previous health problems?*YesNoPlease give details*Have any other pets or person in the household had any illness within the last 30 days?*YesNoPlease give details*Please give details*What are your pet’s current medications? Has your pet received any medications in the last 3 months (heartworm medication, dewormer, flea treatment, etc)*Please attach a photo of your pet’s enclosure or cage.
