Small Mammal History Form

Personal
Owner's Name


Name of Pet(s)


Species


Age


Sex (M/F/Unknown)


How long have you been keeping this species of pet?


How long have you had this pet?


Medical
Purpose of visit


Previous Veterinarian (if any)


If illness, describe signs, duration,and severity:


Coughing (Y/N)


Sneezing (Y/N)


Vomiting (Y/N)


Diarrhea (Y/N)


Lameness (Y/N)


Scratching (Y/N)


List existing or previous medical conditions:


List any medications given


Diet
What food is offered and what is eaten? (Include brand names, frequency, and method of feeding)


Supplements or vitamins


Water
Dish or bottle?


How often is container refilled?


How often is container cleaned?


Housing
Size and type of cage


Type of bedding


Frequency of cleaning


Kept alone or with how many others?


Exercise
Please describe method and frequency of exercise


Handling
How often?


By whom?


Other
Any other pertinent information?