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Animal & Bird Health Care Center
Home
Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Home
Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Small Mammal History Form
*
Indicates required field
Name
*
First
Last
Email
*
Pet's Name
*
This pet
*
is a new patient
has been seen before
Species
*
Date of Birth
*
How long have you had your pet?
*
Gender
*
Male
Female
Neutered Male
Spayed Female
Do you have previous medical records?
*
Yes
No
If you do have previous records, please have them forwarded to us
Where did you obtain your pet?
*
Enviroment
What type of cage does your pet have?
*
Where is the cage located?
*
What kind of bedding do you use?
*
What are the cage dimensions?
*
How often is the cage cleaned?
*
Does Your pet spend time out of the cage?
*
Yes
No
How much time, and, where?
*
Do other animals share the cage?
*
No
One
Two or more
How often is your pet handled
*
For Chinchillas: How often does your pet get a dust bath
*
Where is the dust bath?
*
Diet
What kinds of food and treats do you give your pet?
*
Do you give your pet any vitamin/mineral supplement?
*
Medical History
Please list any previous medical problems
*
If none, write none
Has your pet recently exposed to other animals? Boarding, Grooming, New Addition?
*
Yes
No
Has ther been any change in the pet's enviroment?
*
Have you noticed any of the following?
*
Weight Loss
Weight Gain
Anorexia
Vomiting
Increased Urination
Decreased Urination
Difficulty Urinating
Diarrhea
Excessive Shedding
Hair Loss
Scratching
Skin sores, masses, lumps
Difficulty Breasthing
Coughing
Sneezing
Nasal or Ocular Discharge
Decreased Activity
Lethargy
Loss of Balance
Head Tilt
Wounds
Limping
Pain
Please describe if you have checked any condition
*
Thank you for taking the time to fill out this form. Having this information will allow you to get more out of your time with the doctor.
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