Small Mammal History Form

Date

Owner's Name

First

Last

Email Address

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?

Enviroment

Is 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

If you answered yes to the previous question, how many cage-mates are there? What sex are the cage mates? Are the cage-mates spayed/neutered?

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?

Please describe any recent change to your pet’s diet.

Reproductive

Has this pet been bred before? If yes, how many times?

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?

Is your pet here for a

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?

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 Conditions

Has your pet had any previous conditions, operations or problems (including dental or gastrointestinal problems)?

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

Other

If Other, Please specify

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Small Mammal History Form

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