Email *
Species: *
Gender Male Female Third ChoiceUnknown
Spayed/Neutered Yes No Unknown
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? *
Is the animal kept indoors or outdoors? *
Describe the cage enclosure – type, size, objects in the cage (dust baths, toys, etc.)
What material is used to line the bottom of the cage/litter pan? *
Is the animal kept in a cage with other animals (Y or N)? Yes No
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?
Please list all other pets in the household *
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:
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 and 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? Brand and frequency? *
Please describe any recent change to your pet's diet. *
Has this pet been bred before? If yes, how many times? *
When was it last bred? *
What was the size of all previous litter(s)? Was the litter healthy? *
Do you plan on breeding this pet in the future? *
If your pet is sick, please describe the signs and how long your pet has been showing these signs:
Is your pet's activity level normal Decreased Increased
Is your pet's appetite normal Decreased Increased
medications of your
Have you noticed any of the following? Weight loss Discharge from the eyes or nose A change in the droppings An increased or decreased thirst Weakness
Has your pet had any previous conditions, operations or problems (including dental or gastrointestinal problems)? *
Is your pet currently on any medications? *
Has your pet been on any medications recently? If yes, please list them. *
Is there anything else you would like done today? Nail trim None
Any additional questions?
