SMALL MAMMAL HISTORY FORM Date MM slash DD slash YYYY PATIENT INFORMATIONSpeciesGender Male Female Unknown Spayed / Neutered Yes No Unknown Date of birth/hatch or AgeApproximate ageDate 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?ENVIRONMENTIs the animal kept indoors or outdoors?Describe the cage enclosure – type, size, objects in the cage (dust baths, toys, etc.)What material is used to line the bottom of the cage/litter pan?Is the animal kept in a cage with other animals Yes No How many cage-mates are there? What sex are the cagemates? Are the cage-mates spayed/neutered?Please list all other pets in the householdHave 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?How much time does your pet spend outside of the cage? At all times Sometimes Never Does your pet chew on carpet or other objects/materials when outside of the cage?List recent changes in the environment, if any:DietWhat 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 brand of pelletsAmount of seeds(type/brand)Amount of vegetables(types)Amount of fruits (types)Any other diet (amount and type):How often do you change your pet’sfood?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?Please describe any recent change to your pet’s diet.REPRODUCTIVEHas this pet been bred before? Yes No How many times your pet bred?When was it last bred?What was the size of all previous litter(s)? Was the litter healthy?Do you plan on breeding this pet in the future? Yes No Your pet here for: A well pet check-up Is it sick Please describe the signs of sickness and how long your pet has been showing these signs of sicknessIs your pet’s activity level Normal Decreased Increased Is your pet’s appetitie Normal Decreased Increased Have you noticed any of the following Select All Weight loss Weight gain Discharge from the eyes or nose Increased breathing rate or effort A change in the droppings An increased or decreased thirst Weakness PREVIOUS CONDITIONSHas your pet had any previous conditions, operations or problems (including dental or gastrointestinal problems)?MISCELLANEOUSPrevious vet namePrevious vet location and contact numberIs your pet currently on any medications? Please list them and their dosageHas your pet been on any medications recently? If yes, please list themIs there anything you want us to done today like nail trim etc?Any questions?
