Exotic Patient History Form

Exotic Patient History Form

Owner Information

Owner's Name
Owner's Name
First
Last
How would you like us to contact you?

Pet Information

Sex
Sex Determined By:
Origin
Does this pet have a reproductive history?
Does this pet molt/shed?
Is your pet vaccinated?
Do you have other pets?
Has your pet had any contact with other pets, other than your own, in the last 30 days?
Has your pet received any treatment in the last 30 days?
Have you noticed a change in your pet's behavior?
Have any other animals or persons in the household had any illness in the last 30 days?

Diet Information

Do you use any nutritional supplements?
What water supply do you use?
Do you use any water supplements?
Have you noticed any changes in feeding or drinking behavior?
Have you noticed any changes in droppings (fecal material, urine and urates)?

Environment Information

Are bathing/spraying facilities provided?
Does your pet have exposure to sunlight?
Is your pet exposed to full spectrum (UVA and UVB) lighting?
Does anyone in your household smoke?
Do you use any aerosolized products?
Have there been any changes in the pet's environment in the last 3 months?

Additional Information

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