Rabbit and Rodent History Form - Animal Medical Professionals

OWNER PERSONAL INFORMATION

First Name*:

Last Name:

Email*:

Patient Information

Name:

Species:

Gender:
MFUnknown

Spayed/Neutered:
YesNoUnknown

Date of birth:

Date acquired:

Source (pet store, breeder, previous owner):

Number of previous owners (other than breeder, store):

What states and/or countries has your pet lived in?:

Environment

Is the animal kept indoors or outdoors?:
IndoorsOutdoors

Describe the cage enclosure (size, type, objects in cage – dust bath, toys, etc.):

What type of material is used to line the bottom of the cage/litter pan?:

Is the animal kept in the cage with other animals?:
YesNo
How many cage-mates are there? What sex are the cage-mates? Are the cage-mates spayed or neutered?:
Please list all other pets in the household:
Have there been any new pets (within the last 6 months) placed in this animal’s cage?:

How much time does your pet spend outside of the cage?:

Is your pet supervised when it is out of the cage?:
At all timesSometimesNo

Does your pet chew on carpet or other objects/materials when outside of the cage?:

Please list recent changes in the environment, if any:

Diet

What amount of your pet’s diet consists of the following (please describe what the animal actually eats, not what is offered):
Amount of hay (timothy, alfalfa, etc.):
Amount of pellets (timothy, alfalfa, etc.):
Amount of seeds (type/brand):
Amount of vegetables (types):
Amount of fruits (types):
Other: Amount/type:

How often do you change your pet’s food?:

What (if any) treats do you give your pet (brand and amount)?:

Do you supplement your pet with any vitamins? Is the food or water supplemented with vitamins?:
YesNo
Please list brand and frequency:

Please describe any recent change to your pet’s diet:

Reproductive

Has your pet been bred before? If yes, how many times?:
YesNo
How many times:
When was it last bred?:
What was the size of all previous litters? Were the litters healthy?:

Do you plan on breeding this pet in the future?:
YesNoMaybe

Is your pet here for a:

Check-upIllness
Please describe the signs/symptoms and how long your pet has been showing these signs/symptoms:

Is your pet’s activity level:
NormalDecreasedIncreased

Is your pet’s appetite:
NormalDecreasedIncreased

Previous Conditions

Has your pet had any previous conditions, operations, or problems (including dental or gastrointestinal problems)?:

Miscellaneous

Is your pet currently on any medications?:
YesNo

Has your pet been on any medications recently?:
YesNo
Please list them:

Is there anything else you would like done today?:
YesNo
Please list them:

Are there any additional questions you have for the doctor?:

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