Small Mammal Questionnaire - Luv N Care Animal Hospital

Owner Information

Name*

First Last

Email*

Phone

Address

Street Address Address Line 2 City State ZIP Code

Pet Information

Pet's Name*

Pet's Approximate Date of Birth*

What type of mammal is your pet?*

Of other, please specify

What breed is your pet?

What is your pet's sex?

What brings you and your pet to see us today?*

Who is the primary caregiver for your pet?*

Myself
My child
My Spouse or significant other

Your Pet's Environment

Please describe the home/enclosure/cage your pet lives in, including the type of flooring, bedding, water container type, location of cage in the home, and frequency of cage cleaning*

Does your pet share his cage with any other animals? If so, how many, what species and age?

Are those pets showing similar changes or issues?*

Yes
No
Not Applicable

Your Pet's Diet

Describe what your pet likes to eat! Please include brand, amount and frequency fed (Ex - Oxbow timothy hay free choice and Oxbow adult rabbit pellets - 1/4 cup once a day with one carrot daily)*

Please list any supplements, vitamins, dewormers or medications your pet receives (include brand, mg, frequency and duration pet has been receiving it - Ex: Oxbow vitamin C tablet - one daily, revolution applied on the skin monthly)*

Your Pet's Health Status

Has there been any vomiting?*

Yes
No

Has their been any diarrhea or changes to feces consistency or frequency?*

Yes
No

Has there been any coughing?*

Yes
No

Has there been any sneezing? **

Yes
No

Has your pet been itching or scratching excessively?*

Yes
No

Does your pet have any discharge from its eyes or nose?*

Yes, from the nose
Yes, from the eyes
No

Your Pet's Past Medical History

Has your pet been ill, injured or done poorly in the past? If yes, please describe the diagnosis, treatments, and age at time of illnesses*

Has your pet ever been vaccinated? If yes, what vaccine and when was the last date of vaccination?*

Owner Information

Pet Information

Your Pet's Environment

Your Pet's Diet

Your Pet's Health Status

Your Pet's Past Medical History

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