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

    Species:

    Gender:

    Neutered:

    Is this your first Small Mammal?

    First of this type?

    Date of Birth:

    Date Acquired:

    Acquired from what source?

    ENVIRONMENT

    Indicate Height, Width & Length OR Gallons.

    Substrate

    Cage Accessories:

    Cage Toys:

    Is cage shared with another animal?

    Gender of Cage Mate?

    Are they exposed to this pet?

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

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

    NUTRITION

    Diet

    Vitamin & Mineral Supplements:

    MEDICAL HISTORY

    Please list any medical problems/Primary Complaint:

    Current treatments or supplements:

    Please list any previous medical problems:

    Current Appetite:

    Please describe duration, progress & severity:

    Stools:

    Urination:

    Have you noticed:

    [checkbox haveYouNoticedSmallMammal use_label_element "Weight Loss‎" "Weight Gain‎" "Masses or Lumps (indicate location below)" "Abnormal Urination‎" "Abnormal Stools‎" "Vomiting‎" "Other Discharge (describe below)" ‎"Difficult Breathing‎" "Coughing‎" "Sneezing‎" "Nasal Discharge (describe below)" "Excessive Shedding‎" "Hair Loss‎" "Itching‎" "Skin Sores (indicate location below)" "Poor Posture‎" "Head Tilt‎" "Loss of Balance‎" "Limping (indicate which leg)" ‎"Lethargy‎" "Inactivity‎" "Pain (indicate location below)"]

    Describe details from above or other changes:

    Previous Vet Visits

    Date of last visit:

    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:

    I agree to theterms of service