Ferret History Form


Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear
 understanding of your pet's current health status, we need you to fill out the history form below.
Today's date
First Name
Last Name
Work Phone
Cell Phone
Home Phone
Email
Pet's Name
Gender:
MaleFemaleUnsure
Neutered:
YesNoN/A
Is this your first Ferret?
YesNo
Is this your first PET?
YesNoN/A
Date of Birth:
ActualEstimatedN/A
Date Acquired:
Acquired from what source?
Pet StoreShelterPet ShowBreederPrivate
 PartyOtherN/A
ENVIRONMENT
Approximate Cage Dimensions:
Indicate Height, Width & Length
Substrate
Newspaper‎Care Fresh‎Yesterday’s News‎Wood
 Shavings (cedar – pine)Nothing‎OtherN/A
Does the ferret use a litter box?
YesNoN/A
Which Litter is Used?
How often is the cage cleaned?
Cage Accessories:
Sleeping Bag‎Hammock‎Towels‎Climbing
 Toys‎Shelves‎N/A
Cage Toys:
Play Tubes‎Chew Toys‎Exercise Wheel‎OtherN/A
Is cage shared with another ferret?
YesNo
Gender of Cage Mate?
MaleFemaleUnsureN/A
Other pets in the home:
Are they exposed to this pet?
YesNoN/A
In what way?
How much time does your ferret get out of its cage per day?
Please indicate total minutes.
Is your pet supervised when it is outside of its cage?
YesUsuallyNoN/A
NUTRITION
Diet (Please describe in detail)
List everything the ferret eats:
Vitamin & Mineral Supplements:
MEDICAL HISTORY
Please list any medical problems/Primary Complaint:
Current treatments or supplements:
Please list any previous medical problems (Please Indicate Dates % Treatments):
Vaccinations
Distemper?
YesNoN/A
When?
Which Product?
Rabies?
YesNoN/A
When?
Which Product?
Other Vaccines and/or ANY adverse effects? (Please include when given.)
Current Appetite:
NormalIncreasedDecreasedAnorexicN/A
Have you noticed:
Weight Loss‎Weight Gain‎Masses or Lumps(indicate location below)Abnormal Urination‎Abnormal Stools‎Vomiting‎Other Discharge(describe below)Difficult Breathing‎Coughing‎Sneezing‎Nasal discharge(describe below)Excessive Shedding‎Hair Loss‎Itching‎Skin Sores(indicate location below)Lethargy‎Inactivity‎Deep Sleep‎Pain(indicate location below)‎N/A
Describe details from above or other changes:
Former Vet Visits
YesNoN/A
Doctor's Name
Date of last visit:
Doctor's Phone
Doctor's Clinic
Records Requested
YesNoN/A
Received
YesNoN/A
Previous Lab Tests / Diagnostics:
YesNoN/A
Date of testing:
Tests Conducted:
Complete Blood Count‎Chemistry Profile‎Fecal
 Exam‎Bacterial Culture‎Radiographs (X-ray)‎N/A
Other Tests:
Abnormal Results:
Results Requested:
YesNoN/A
Sent to Clinic?
YesNoN/A
Your Signature
      
To the best of my knowledge, the information provided above and on the patient history form is accurate and
 complete. I authorize you to contact my referring veterinarian if clarification of medical history is needed or
 to acquire previous veterinary records, I understand that payment is due at the time services are rendered. I
 agree to pay all charges at the time my pet is discharged.
Data Privacy and Consent:
I agree to theterms of service
Ferret History Form

ENVIRONMENT

NUTRITION

MEDICAL HISTORY

Vaccinations

Your Signature

AFFILIATIONS:

Patient Portal
