Pocket Pet History Form

Thank you for choosing Companion Animal Hospital; We welcome the opportunity to care for your pet(s).

Date*

Admitting Clinician:*

Appointment Time:*

RDVM Information:

Name of Animal:*

Breed:*

Sex:*

Age

Companion Animal/Breeder:

Length of time owned:

Where acquired?

If other is selected, please specify here:

How often is animal handled?

Character of Feces

Husbandry:

Housed?

Is animal allowed to roam free in the house?

Where is cage located?

Type of Caging:

Galvanized?

Size of Cage:

Cage Substrate:

How often is cage cleaned?

What type of disinfectant is used when cleaning cage?

Type of cage furniture:

Are there chew toys available in cage?

What are they made of?

Type of food offered:

If Pallets, what brand?

Amount fed/frequency:

Supplements offered and frequency (i.e., seeds, vegetables, etc.):

Water source:

How often is water changed?

Any other pets?

If yes, specify:

Any other pocket pets?

If yes, specify:

Are animals housed together or singly?

If not housed together, where are the other animals located?

Any new additions to the pocket pet population?

If yes, specify:

Past Medical History/Problems:

Current presenting problem:

Duration of complaint: