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? *
Name Signature and
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
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?
