Belleway Veterinary Hospital 6833 Hwy 62, RR 5 Belleville , Ontario K8N 4Z5 (613) 969-0537 |
Rabbit & Rodent History Form
Date: ___________________
Instructions: An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information. Plaese check the appropriate boxes or use the spaces provided. Thank-you.
1. Patient Information
Species: __________________
Gender: Male ____ Female ____ Unknown _____
Spayed/Neutered (Y, N, or Unknown) ____
Date of Birth: _______________
Date acquired and source (pet store, breeder, previous owner): ______________
Number of previous owners (other than breeder, store): ____
What states and countries has your pet lived in? ____________________________
2. Environment
Is the animal kept indoors or outdoors? ____________________
Describe the cage enclosure – type, size, objects in the cage (dust baths, toys, etc.)
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What material is used to line the bottom of the cage/litter pan?
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Is the animal kept in a cage with other animals (Y or N)? ____
If you answered YES to the previous question, how many cage-mates are there? What sex are the cage-mates? Are the cage-mates spayed/neutered?
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Please list all other pets in the household ___________________________________
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Have there been any new pets (within the past six 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?
____ all times ____ sometimes ____ No
Does your pet chew on carpet or other objects/materials when outside of the cage? ________________________________________________________________
List recent changes in the environment, if any: ________________________________________________________________________
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3. 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)? _______________
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Do you supplement your pet with any vitamins? Is the food or water supplemented with vitamins? Brand and frequency?
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Please describe any recent change to your pet's diet. ______________________
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4. Reproductive
Has this pet been bred before? If yes, how many times? ____________________
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When was it last bred? ___________________________________________________
What was the size of all previous litter(s)? Was the litter healthy? _______________
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Do you plan on breeding this pet in the future? _____________________________
5. Is your pet here for a well pet check-up ____ or is it sick ____
(check one)?
If your pet is sick, please describe the signs and how long your pet has been showing these signs: _____________________________________________________
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Is your pet's activity level normal _____, decreased ____, or, increased ____ ?
Is your pet's appetite normal ____, decreased ____, or, increased ____ ?
Have you noticed any of the following?
__ weight loss
__ weight gain
__ discharge from the eyes or nose
__ a change in the droppings
__ an increased or decreased thirst
__ weakness
6. Previous Conditions:
Has your pet had any previous condiitons, operations or problems (including dental or gastrointestinal problems?) ____________________________________
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7. Miscellaneous
Is your pet currently on any medications? ________________________________
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Has your pet been on any medications recently? If yes, please list them. ____
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8. Is there anything else you would like done today?
__ Nail trim
__ Have questions about: _____________________________________________
__ Other: ____________________________________________________________