Pre-Register at the Gentle Vet Animal Hospital SMALL MAMMAL HISTORY FORM   Print this page and fill out before coming in: Print  When finished printing page, click here to return to:  Registration Page Your pet's name:__________________________ Sex: M F Unknown Species:__________________________________ How long have you owned your pet?______________________________________________________ If your pet is a female, has she ever given birth?____________________________________________ Is your pet used for breeding?__________________________________________________________ Where did you get this animal? (Breeder, private home, pet store, surrendered)______________________ Are there any other animals in the house? If yes, how many and what kind?_________________________ _________________________________________________________________________________ Have there been any recent changes in the household? (new people, pets, remodeling)__________________ _________________________________________________________________________________ Housing Where is your pet kept? In detail (%of the time)______________________________________________ __________________________________________________________________________________ Describe your pet's cage (size, shape, toys, hiding/sleeping facilities)_____________________________ __________________________________________________________________________________ Is your pet housed alone?______________________________________________________________ List day/night temperature of your pet's enclosure.___________________________________________ What do you cover the bottom of the cage with?_____________________________________________ How often is the cage cleaned and what do you use to clean it?_________________________________ _________________________________________________________________________________ Does anyone smoke inside the house?_____________________________________________________ Diet What foods are offered and in what amounts? (e.g. for rabbits, 90% hay and 10% pellets)_____________ _________________________________________________________________________________ Do you feed any treats? How often, what kind, how many?______________________________________ Has there been any recent diet change? Describe:____________________________________________ How is the water supplied? (e.g. sipper bottle, bowl, cage cup)_______________________________ Health Have you notice any change in your pet's behavior? (more sleeping, more aggressive, hiding, etc.)_________ __________________________________________________________________________________ Have you noticed any change in your pets droppings? (e.g., frequency, color, loose or firm)_____________ __________________________________________________________________________________ Is anyone in your house immunocompromised? (very young or old, receiving chemotherapy or an organ transplant)__________________________________________________________________________ Reason for today's visit What signs have you noticed that prompted today's visit?_______________________________________ __________________________________________________________________________________ How long have you noticed the problem?___________________________________________________ Has your pet been sick previously?_________________________________________________________ Has your pet been seen by another doctor? If yes, when and for what purpose?______________________ __________________________________________________________________________________ Have any tests been previously conducted on your pet? (blood work, x-rays, fecal tests, other)___________ __________________________________________________________________________________ Does your pet take any medications? If yes, what kind and for how long?_________________________ Additional comments, concerns, or requests: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________