Mammal History Form

A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about, you can discuss it in more depth with the veterinary staff during your appointment.

Client Information

Animal Details

Name or identification:

Common or scientific species name:

Date of birth:

Age:

Sex: M M Neutered F F Spayed Unknown

How long have you had this animal?

From where did you obtain this animal?

Is your animal vaccinated?

List vaccines and dates given:

If applicable, do you have a license (DNR/USDA) to own this animal?

(Please bring your license with you as a photocopy will be required for the medical record)

Do you have any other pets in the household?

If so, list the number and the species.

When was the last animal added to your household?

Has your pet had contact with any other animals in the last 30 days?

Do people who have contact with the animal have comparable signs as seen in your animal?

Cage Environment

Where is the cage located?

Please give details:

What percentage of time does your animal spend inside and outside of its cage?

Is the animal supervised when out of the cage?

What is the cage made of?

What are the dimensions of the cage?

Have there been any changes in the environment in the last three months?

Please give details:

What décor and furnishings are present?

Is there ventilation (grills or mesh)?

Please give size/details:

What bedding do you use? Please give details:

Is your animal litter trained?

Do you provide any bathing facilities?

Please give details:

What is your animal's day and night cycle?

Are there any smokers in the house?

Do you use aerosolized substances?

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

Diet

How often do you feed your animal?

Indicate which foods are eaten and in what amounts (by number, weight, or approx.. volume):

Pellets:

Vegetables

Treats:

Hay:

Fruits:

Other details?

Do you use any nutritional supplements?

if yes what, how much, and how often:

What water supply do you provide?

How is water provided? Bowl/dripper system

How often is the water source changed?

Do you use any water supplements?

Please give details:

Reason for Presentation Today

What is the primary complaint or what signs you have noticed?

Has this animal received any medication for this primary complaint? If so, what medication has been given, at what dosage and duration? What was the effect of this medication on the primary complaint?

Has this animal had previous health problems?

Please give details:

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

Has your animal received any medications in the last three months (i.e. heartworm medication, dewormer, flea treatments)

General Condition and Functioning

Please provide any changes to the following topics:

Appetite and food intake:

Drinking:

Feces and defecation:

Urine and urination:

Behavior, activity, and locomotion:

Any aspects that need further attention:

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