Exotic Patient History Form Exotic Patient History Form Owner Information Owner's Name * Owner's Name First First Last Last Email * Best Phone Number to Reach You * Secondary Phone Number How would you like us to contact you? * Phone Call Text Message Email Pet Information Pet Name or Identification * Pet Species and Breed * Age/DOB * Sex * Male, intact Male, neutered Female, intact Female, spayed Unknown Sex Determined By: * DNA Endoscopy Visual Other Unknown Origin * Captive Bred Wild Caught Unknown From where did you obtain this pet? * How long have you had this pet? * Does this pet have a reproductive history? * Yes No Unknown Please give details * Does this pet molt/shed? * Yes No Unknown When did your pet last molt/shed? * How often does your pet molt/shed? * Is your pet vaccinated? * Yes No Unknown Please list which vaccines * Do you have other pets? * Yes No Please list other animals in the household, including breed, sex, and age; if we do not have them on file * Has your pet had any contact with other pets, other than your own, in the last 30 days? * Yes No Unknown Please give details * When was the last pet added to your collection? What is the primary complaint or what signs have you noticed? How long have these problems been present? * What problems has your pet had recently? * Has your pet received any treatment in the last 30 days? * Yes No Unknown Please give details (What was used, dosage, how often, duration) * Have you noticed a change in your pet's behavior? * Yes No Unknown Please give details * Have any other animals or persons in the household had any illness in the last 30 days? * Yes No Unknown Please give details * Diet Information How often do you feed your animal? * Which foods are eaten? Pellets, fruits, vegetables, meat, insects, treats, other? Please be specific with brand, type, and in what amounts (by number, weight, or approx. volume) * Do you use any nutritional supplements? * Yes No Unknown Please indicate what, how much, and how often * What water supply do you use? * Tap Water Bottled Water Rain/River Water How is the water provided and how often? * How often is the water changed? * Do you use any water supplements? * Yes No Unknown Please give details * Have you noticed any changes in feeding or drinking behavior? * Yes No Unknown Please give details * Have you noticed any changes in droppings (fecal material, urine and urates)? * Yes No Unknown Please give details * Environment Information Enclosure loction? Inside or outside? What temperature is the enclosure kept at? Other details * What is the size of the cage and what is the cage made of? * What kind of bedding is used? * What decor and furnishings are present (hide box, perches, toys, others)? Please give details * Are bathing/spraying facilities provided? * Yes No Unknown Please give details * How often is the cage cleaned and what cleaning/disinfectant agents are used? * What percentage of time does your pet spend inside and outside of it's cage? * Is the animal supervised when out of the cage? Please give details * Does your pet have exposure to sunlight? * Yes No Unknown Frequency and length of time? * Is your pet exposed to full spectrum (UVA and UVB) lighting? * Yes No Unknown Brand? * What is your pet's light/dark cycle? Does anyone in your household smoke? * Yes No Unknown Do you use any aerosolized products? * Yes No Unknown Please give details * Have there been any changes in the pet's environment in the last 3 months? * Yes No Unknown Please give details * Additional Information Please provide any other comments or details of relevance In the event further diagnostics and/or treatments are needed, and we are unable to reach you, please indicate how you would like us to proceed Perform any additional diagnostics and/or treatments. Call or text me first. If you cannot reach me, you may proceed with any diagnostics and/or treatments deemed necessary. Do nothing else unless you contact me. Signature * signature keyboard Clear Date * Captcha If you are human, leave this field blank. Submit
