Non-Reptile Exotic Questionnaire Please enable JavaScript in your browser to complete this form.OWNER INFORMATION Name: *Phone Number: * PATIENT INFORMATION Name: *Species: *Gender: *MaleFemaleSpayed/Neutered? *YesNoDate 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? *YesNoIf 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? *YesNoDoes your pet chew on carpet or other objects outside of the cage? *YesNoList 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? *YesNo Is the food or water supplemented with vitamins? *YesNoVitamin brand and frequency:Describe any recent changes to your pets diet: GENERAL HEALTH Activity level: *normaldecreasedincreasedAppetite *normaldecreasedincreasedHave you noticed any of the following: *Weight lossWeight gainDischarge from eyes or noseIncreased breathing rate or effortChange in droppingsIncreased or decreased thirstWeaknessCecotropes (rabbits)If you selected Cecotropes (rabbits), then how often?Is your pet on any medications? *YesNoIf yes, please list: Previous conditions Has your pet had any previous conditions, operations, or problems (including dental or gastrointestinal problems)? *YesNoIf yes, please describe:Is there anything else you would like done for today?Submit
1350 S Fish Hatchery Rd. Oregon, WI 53575