Exotic Mammal History Form Name or Identification*Common/Scientific species name*Date of Birth* MM slash DD slash YYYY Age*Sex* Male Female Male/Neutered Female/Spayed UnknownHow long have you had this animal?*From where did you obtain this animal?*Is your animal vaccinated?* Yes NoIf yes, please list vaccines and dates given:*If applicable, do you have a license (DNR/USDA) to own this animal? Yes NoDo you have any other pets in the household?* Yes NoIf yes, list the number and species:*When was the last animal added to your household?*Has your pet had contact with any other animals in the last 30 days?* Yes NoIf yes, when and what species?*Cage EnvironmentCage location* Inside OutsideWhat is the cage made of and what are the dimensions?*Have there been any changes in the environment in the last 3 months?* Yes NoDetails:*What decor and furnishings are present?*Is there ventilation* Yes NoVentilation details:*What bedding do you use?*Is your animal litter trained?* Yes NoDo you provide any bathing facilities?* Yes NoGive details*Animal's day/night cycle*Are there smokers in the house?* Yes NoDo you use aerosolized substances?* Yes NoHow often is the cage cleaned?*What cleaning/disinfectant agents are used?*DietHow often do you feed your animal?*Which foods are eaten and in what amounts (by weight or approximate volume)*Nutritional Supplements – Type/Amount/FrequencyWhat water supply do you provide?* Tap water Bottled water Rain/River waterHow is water provided?* Bowl Dripper SystemHow often is the water changed?*Do you use any water supplements?* Yes NoDetails*Have you noticed any changes in feeding or drinking behavior?* Yes NoDetails*Have you noticed any changes in the droppings?* Yes NoDetails*Reason for Presentation TodayWhat is the primary complaint or what signs you have noticed?*Has this animal had previous health problems?* Yes NoDetails*Have any other animals or persons in the household had any illnesses within the last 30 days?* Yes NoDetails*Has your animal received any medications in the last 3 months (i.e. heartworm medication, dewormer, flea treatments)? Yes NoDetails*Any additional comments or details of relevance?*PhoneThis field is for validation purposes and should be left unchanged.Δ
