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 Unknown How long have you had this animal?* From where did you obtain this animal?* Is your animal vaccinated?* Yes No If yes, please list vaccines and dates given:*If applicable, do you have a license (DNR/USDA) to own this animal? Yes No Do you have any other pets in the household?* Yes No If 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 No If yes, when and what species?* Cage EnvironmentCage location* Inside Outside What is the cage made of and what are the dimensions?* Have there been any changes in the environment in the last 3 months?* Yes No Details:*What decor and furnishings are present?*Is there ventilation* Yes No Ventilation details:*What bedding do you use?* Is your animal litter trained?* Yes No Do you provide any bathing facilities?* Yes No Give details*Animal's day/night cycle*Are there smokers in the house?* Yes No Do you use aerosolized substances?* Yes No How 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 water How is water provided?* Bowl Dripper System How often is the water changed?* Do you use any water supplements?* Yes No Details*Have you noticed any changes in feeding or drinking behavior?* Yes No Details*Have you noticed any changes in the droppings?* Yes No Details*Reason for Presentation TodayWhat is the primary complaint or what signs you have noticed?*Has this animal had previous health problems?* Yes No Details*Have any other animals or persons in the household had any illnesses within the last 30 days?* Yes No Details*Has your animal received any medications in the last 3 months (i.e. heartworm medication, dewormer, flea treatments)? Yes No Details*Any additional comments or details of relevance?*NameThis field is for validation purposes and should be left unchanged. Δ
