Client Information
Your Name
(Required)
First
Last
Spouse/Other
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Louisiana
Maine
Maryland
Massachusetts
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Mississippi
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Montana
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New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Animal Details
Name or identification:
Common or scientific species name:
Date of birth:
MM slash DD slash YYYY
Sex
Choose One
Male
Female
Spayed/Neutered
Choose One
Yes
No
Unknown
How long have you had this animal?
From where did you obtain this animal?
Is your animal vaccinated?
Choose One
Yes
No
List vaccines and dates given:
If applicable, do you have a license (DNR/USDA) to own this animal?
Choose One
Yes
No
(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?
Choose One
Yes
No
List the number and the species.
When was the last animal added to your household?
MM slash DD slash YYYY
Has your pet had contact with any other animals in the last 30 days?
Choose One
Yes
No
Do people who have contact with the animal have comparable signs as seen in your animal?
Choose One
Yes
No
Cage Environment
Where is the cage located?
Choose One
Inside
Outside
Please give details
Is the animal supervised when out of the cage?
Choose One
Yes
No
What percentage of time does your animal spend inside and outside of its 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?
Choose One
Yes
No
Please give details
What décor and furnishings are present?
Is there ventilation (grills or mesh)?
Choose One
Yes
No
Please give size/details
What bedding do you use? Please give details:
Is your animal litter trained?
Choose One
Yes
No
Do you provide any bathing facilities?
Choose One
Yes
No
Please give details
What is your animal's day and night cycle?
Are there any smokers in the house?
Choose One
Yes
No
Do you use aerosolized substances?
Choose One
Yes
No
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:
Amount & Frequency?
Vegetables:
Amount & Frequency?
Treats:
Amount & Frequency?
Hay:
Amount & Frequency?
Fruits:
Amount & Frequency?
Other details?
Do you use any nutritional supplements?
Choose One
Yes
No
What, how much, and how often?
How is water provided? Bowl/dripper system
How often is the water source changed?
Do you use any water supplements?
Choose One
Yes
No
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?
Choose One
Yes
No
Please give details
Have any other animals or persons in the household had any illness within the last 30 days?
Choose One
Yes
No
Please give details
Has your animal received any medications in the last three months (i.e. heartworm medication, dewormer, flea treatments)
Choose One
Yes
No
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:
Date
(Required)
MM slash DD slash YYYY
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