Small Mammal History Form – Town & Country Animal Hospital

Owner's First and Last Name*

First Last

Pet's Name*

First

Species / Breed Name*

Please enter your pets age / Date of Birth*

How long have you had this pet?*

Where did you obtain this pet?*

Please select your pets sex*

How was your pets gender determined?*

Do you have other pets?*

If answered yes, please describe

Have you or your pet had contact with any other pets in the last 30 days?*

If answered yes, please provide details

What is your primary concern? What signs/symptoms have you noticed? How long have these problems been present?*

Have you noticed any changes in your pets behavior? ( Not eating or drinking, teeth grinding teeth, etc. )*

If answered yes, please provide details

Which food do you feed to your pet?*

Please describe your pets diet in more detail ( brand, amount etc. )

Do you use any nutritional supplements?*

If answered yes, please provide details

Have you noticed any changes in droppings? (feces or urine)*

If answered yes, please provide details

What kind of bedding is used?*

How often is the enclosure cleaned?*

Is your pet supervised when out of the enclosure?*

Please add any other comments / information here: