Mammal History Form Required Fields in Red ANIMAL DETAILS Name or Identification: Common / Scientific Species Name: Date of Birth: Age: Sex: MM/NeuteredFF/SpayedUnknown How long have you had this animal? From where did you obtain this animal? Is your animal vaccinated? YesNo List vaccines & dates given: If a primate, has your animal been tuberculosis (TB) tested? YesNo If yes, when? If applicable, do you have a license (DNR/USDA) to own this animal?? YesNo (Please bring your license with you as a photocopy will be required for the medical record) Do you have any other pets in the household? YesNo If so, list the number and the species: When was the last animal added to your household? Has your pet had contact with any other animals in the last 30 days? CAGE ENVIRONMENT Where is the cage located? InsideOutside Provide details: What percentage of time does your animal spend in the cage? Is your animal supervised when out of the cage?: YesNo What is the cage made of? What are the dimensions of the cage? Have there been any changes in the environment in the last 3 months? YesNo Give details: What decor & furnishings are present? Is there ventilation (grills or mesh)? YesNo Give size/details: Is your animal litter trained? YesNo What bedding do you use? Please give details Do you provide bathing facilities? Please give details What is your animal's day & night cycle? Are there any smokers in the house? YesNo Do you use aerosolized substances? YesNo How often is the cage cleaned? What cleaning/disinfectant agents are used? DIET How often do you feed your animal? Indicate which foods are eaten, and in what amounts (by weight, or approx volume) Pellets NoYes Brand/amount? Vegetables NoYes Type/amount? Treats NoYes Type/Amount? Hay NoYes Type/amount? Fruits NoYes Type/amount? Meat or meat products NoYes Type/amount? Other NoYes Details? How often do you feed your animal? Do you use any nutritional supplements? YesNo If yes then what, how much, and how often: What water supply do you provide? tap waterbottled waterrain/river water How is water provided? bowldripper system Please give details: How often is the water changed? Do you use any water supplements? YesNo Please give details: Have you noticed any changes in feeding or drinking behavior? Please give details: Have you noticed any changes in the droppings? Please give details REASON FOR PRESENTATION TODAY What is the primary complaint or what signs have you notice? Has this animal had previous health problems? Please give details: Have any other animals or persons in the household had any illness within the last 30 days? Has your animal received any medications in the last 3 months (i.e. heartworm medication, dewormer, flea treatments)
