608-835-0551 customerservice@countryviewvets.com

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1350 S Fish Hatchery Rd. Oregon, WI 53575

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Please Note: We will be closing early at noon on Tuesday, December 24th and will be closed on Wednesday, December 25th in observance of Christmas!

Non-Reptile Exotic Questionnaire

OWNER INFORMATION

Name: *

Phone Number: *

PATIENT INFORMATION

Name: *

Species: *

Gender: *

Male
Female

Spayed/Neutered? *

Yes
No

Date of Birth: *

Where did you get your pet? *

How long have you had your pet? *

Has this pet had other owners? *

ENVIRONMENT

Is your pet kept indoors or outdoors? *

Describe your pets environment/cage/enclosure: *

What kind of bedding/substrate do you use? *

How often do you clean your pets enclosure? *

What do you use to clean your pets enclosure? *

Is your pet kept in the cage with other animals? *

Yes
No

If yes, how many cage-mates are there?

What sex are the cage-mates?

Are the cage-mates spayed or neutered?

List all other pets in the house:

How much time does your pet spend outside of the cage? *

Is your pet supervised when out of the cage? *

Yes
No

Does your pet chew on carpet or other objects outside of the cage? *

Yes
No

List any recent changes in the environment, if any:

DIET

What amount of your pets diet consists of the following (please describe what your pet actually eats, not what is offered)

Amount of hay (timothy, alfalfa, etc.): *

Amount of pellets: *

Amount of seeds (type/brand): *

Amount of vegetables (types): *

Amount of fruits (types): *

Other:

How often do you change your pets food? *

What (if any) treats do you give your pet (brand and amount)? *

Do you supplement your pet with any vitamins? *

Yes
No

Is the food or water supplemented with vitamins? *

Yes
No

Vitamin brand and frequency:

Describe any recent changes to your pets diet:

GENERAL HEALTH

Activity level: *

normal
decreased
increased

Appetite *

normal
decreased
increased

Have you noticed any of the following: *

Weight loss
Weight gain
Discharge from eyes or nose
Increased breathing rate or effort
Change in droppings
Increased or decreased thirst
Weakness
Cecotropes (rabbits)

If you selected Cecotropes (rabbits), then how often?

Is your pet on any medications? *

Yes
No

If yes, please list:

Previous conditions

Has your pet had any previous conditions, operations, or problems (including dental or gastrointestinal problems)? *

Yes
No

If yes, please describe:

Is there anything else you would like done for today?

Book An Appointment

At Country View Veterinary Service of Oregon, we want to be welcoming to people and their pets. We pay attention to your pets’ needs, and understanding your concerns are significant. Please book an appointment for your pet using our online system.

Book Appointment

Have a question?

Get in touch! Complete our online form and we will be in touch with you shortly.

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Location

1350 S Fish Hatchery Rd.
Oregon, WI 53575

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Contact Information

P: 608-835-0551
E: customerservice@countryviewvets.com

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Hours

Mon-Fri: 8:00 AM – 6:00 PM
Sat: 8:00 AM – 2:00 PM
Sun: Closed

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