Patient Name:  

Breed:

  Sex:  Female   Female Spayed    Unknown

           Male      Male Neutered 

 

 Color and Markings:

 

Birth/Hatch Date or Age:

  Where purchased or acquired:

Number of hours your pet spends outside each day:

 

 

Previous medical or behavior problems, treatments, testing:

Last Molt or Shed:

Present medical or behavior problems:

 

Current medications, special diets, etc:

 

Known drug allergies:

 

NONE

  Housing Information:

Is your pet caged?   Yes No 

If yes, what size and type of cage:

 

Primary substrate or bedding:

Location in home:

High traffic area:    Yes   No

Near window or draft?   Yes   No

Is there a place for the pet to hide?   Yes    No

Is your pet allowed undisturbed sleep time?   Yes    No

If yes, how long?

Length of daily light exposure:

List all types of basking lights used:

Access to unfiltered sunlight?  Yes    No

Is temperature regulated?   Yes   No

If yes, list temperature range and equipment used (heat lamps, rocks)

Is humidity regulated?  Yes    No

Is pet bathed or soaked or misted regularly?  Yes    No

For aquatic species: Is swimming area temperature regulated? 

                                                   Yes    No

List all toys in cage:

What type of perches and how many are used?

How often is the cage cleaned and what supplies are used?

Amount of time spent outside of cage each day:

Is pet supervised when out of cage?   Yes     No

Amount of time spent outdoors:

Are there any other pets in the household?   Yes    No

If so, which come into contact or close proximity to this pet?

Diet:

What type of diet is offered daily, please give approximate percentage of each

component:

From what is offered, what does your pet eat:

Is table food given?  Yes    No

Are supplements or vitamins given?  Yes    No

If yes, please list what they are:

For carnivorous species: Is food fed alive   or frozen

Are insects fed gut-loaded?   Yes    No

Are they dusted with calcium?  Yes    No

 

If you are transferring from another animal hospital please have your pet’s medical history faxed to us in advance of your appointment at (585) 388-0202

 

This is the only pet I want to submit at this time

I will also fill out information on another pet of mine

 

       

 

Signature of Owner: ___________________________________

                                      

Date: ________________________________________________

(to be signed at the time of this pet’s first appointment)

Please fill out information for only ONE patient at a time, thanks.

“Miss Piggy” came for her check up before being spayed

“Kansas” came to see us when she wasn’t feeling well

An assortment of fuzzy baby chicks