Small Mammal 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

    Species:

    Gender:

    Neutered:

    Is this your first Small Mammal?

    First of this type?

    Date of Birth:

    Date Acquired:

    Acquired from what source?

    ENVIRONMENT

    Approximate Cage Dimensions:

    Indicate Height, Width & Length OR Gallons.

    Substrate

    How often is the cage cleaned?

    Cage Accessories:

    Cage Toys:

    Is cage shared with another animal?

    Gender of Cage Mate?

    Other pets in the home:

    Are they exposed to this pet?

    In what way?

    How much time does your pet get out of its cage per day? (Minutes per day)

    Is your pet supervised when it is outside of its cage?

    NUTRITION

    Diet (Please describe in detail.)

    List everything the Small Mammal 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)

    Current Appetite:

    Please describe duration, progress & severity:

    Stools:

    Color...

    Consistency...

    Amount...

    Frequency...

    Urination:

    Urine Color...

    Urine Frequency...

    Urine Amount...

    Have you noticed:

    Describe details from above or other changes:

    Previous Vet Visits

    Doctor's Name

    Date of last visit:

    Doctor's Phone

    Doctor's Clinic

    Records Requested

    Received

    Previous Lab Tests / Diagnostics:

    Date of testing:

    Tests Conducted:

    Other Tests:

    Abnormal Results:

    Results Requested:

    Sent to Clinic?

    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:

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