Exotic Mammal History Form

Step 1 of 4 - Patient (Animal) Information

25%

Client/Owner Name(Required)

Phone(Required)

Patient (Animal) Information

Patient Name or Identification(Required)

Species/Breed(Required)

Date of Birth/Age(Required)

Sex(Required)

Male, intact

Male, neutered

Female, intact

Female, spayed

Unknown

How long have you had this animal?(Required)

From where did you obtain this animal?(Required)

Pet Store

Breeder

Rescue/Sanctuary

Other

Is your animal vaccinated?(Required)

Yes

If yes, please list vaccines and dates given:(Required)

Vaccine

Date Given

If a primate, has your animal been tuberculosis (TB) tested?

Yes

If yes, when?(Required)

Do you have a license (DNR/USDA) to own this animal?

Yes

If yes, please upload a copy of the license here:

Accepted file types: pdf, doc, docx, odt, jpg, jpeg, gif, png, bmp, tiff, tif, webp, Max. file size: 50 MB.

Do you have any other pets in the household?(Required)

Yes

Please list the species of the other pets and when they were added to the household(Required)

Species

Added to Household

Has the animal had any contact with any animals outside your household within the past 30 days?(Required)

Yes

If yes, please describe:(Required)

Cage/Enclosure Environment

Where is the cage/enclosure located?(Required)

Indoors

Outdoors

Other

Please describe where the cage/enclosure is located:(Required)

What percentage of time does your animal spend in the cage/enclosure?(Required)

Is your animal supervised when out of the cage?

Yes

Is there ventilation (grills or mesh)?(Required)

Yes

What is the cage/enclosure made of?(Required)

What are the dimensions/size of the cage/enclosure?(Required)

Please attach a picture of the cage/enclosure(Required)

Accepted file types: jpg, jpeg, png, gif, tiff, tif, webp, bmp, Max. file size: 50 MB.

Please list any décor, furnishing, toys, etc that are present in the cage/enclosure(Required)

Type (i.e bedding, décor, toy, furninshing)

Product Made out of (i.e. plastic, wood, wool)

Brand Name

How often is the cage/enclosure cleaned?(Required)

Daily

Weekly

Bi-Monthly

Monthly

Never

Other

What cleaning products are used?(Required)

Is your animal litter trained?(Required)

Yes

If yes, please provide the name, type, and brand of litter:(Required)

Does anyone in the house smoke or is the animal around smoke?(Required)

Yes

Do you use aerosolized substances/cleaners/air fresheners?(Required)

Yes

If yes, please list with brand name and frequency of use:(Required)

Brand Name

Frequency of Use

Have there been any changes in the environment in the last 3 months?(Required)

Yes

If yes, please provide details:(Required)

Diet/Feeding Regiment

Please list what foods are eaten, how often they are fed, and in what amounts (i.e. weight or approximate volume). Please use the appropriate section for each type of food.

Pellets

Brand Name

Amount

Frequency Fed

Vegetables

Type

Frozen, Fresh, Freeze-Dried

Amount

Frequency Fed

Hay

Type

Amount

Frequency Fed or Changed

Fruits

Type

Frozen, Fresh, Freeze-Dried

Amount

Frequency Fed

Treats

Type

Brand Name

Amount

Frequency Fed

Meat or Meat Products

Type

Brand Name

Amount

Frequency Fed

Other Food Types

Type

Brand

Amount

Frequency Fed

Nutritional Supplements

Type

Brand

Amount

Frequency Fed

What type of water is provided?(Required)

Tap Water (City)

Tap Water (Well)

Bottled/Filtered Water

Rain/River Water

If bottled/filtered water is provided, what brand/type?(Required)

How is the water offered?(Required)

Bowl

Dripper System

Other

Bowl Size(Required)

How frequently is the bowl cleaned?(Required)

How frequently do you change the water in the bowl?(Required)

Dripper System Size(Required)

How frequently is the dripper system cleaned?(Required)

How frequently do you change the water in the dripper system?(Required)

If other, please describe: (including size)(Required)

How frequently is it cleaned?(Required)

How frequently do you change the water?(Required)

Have you noticed any changes or have any concerns about your animal's feeding or drinking behavior?(Required)

Yes

If yes, please provide details:(Required)

Have you noticed any changes or have any concerns about your animal's droppings?(Required)

Yes

If yes, please provide details:(Required)

Appointment Information/Reason

Main Reason/Concern for Visit(Required)

Have you noticed any signs, symptoms, or changes in behavior that are concerning?(Required)

Yes

If yes, please list:(Required)

Sign/Symptom

Date First Noticed

Any Treatments Provided

Does this animal have any previous medical or health problems?(Required)

Yes

Have any other animals or persons in the household had any illness within the last 30 days?(Required)

Yes

Has your animal received any preventative medications within the past 3 months? (i.e. heartworm, flea treatment, dewormer, etc)(Required)

Yes

If yes, please list:(Required)

Medication/Treatment

Dosage

How Often was it Given

Duration

CAPTCHA

Patient (Animal) Information

Cage/Enclosure Environment

Diet/Feeding Regiment

Appointment Information/Reason

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