Weight
Email *
Patient Name
Species
If sex is known, how was it determined?
Is your pet spayed (female) or neutered (male)?
Origin of pet
If this pet is wild caught or from a breeder, please explain:
Length of ownership
Age/Date of Birth
Band number/Microchip
Size of cage or cages
Where is the enclosure housed?
% day confined to enclosure vs. free roaming
How often is cage cleaned?
What is used to clean the cage?
What substrate/bedding is used in the enclosure?
Types of perches (if applicable)
Amount of exposure daily
Temperature of cage? Heat source?
How often is pet bathed?
What is used to bathe pet?
Other access? Play perches, floor, tables, outside, vacation home, etc
If Other, please explain:
Please elaborate on their enrichment.
If Other toys, please explain:
Species
Age(s)
Amount of contact between other pets and above patient
Any known diseases with any other pet(s) within the household
What food (include brand) is the pet provided?
What does the pet actually eat?
How are non-commercial diet foods prepared?
How frequently is water offered?
How frequently are water bowls cleaned?
Describe any exercise your pet receives, and how often.
Has your pet had any vaccines? If so, please list vaccine(s) and most recent date of vaccination.
Is your pet currently on any medications? If so, please list medication, dosage, and frequency.
What is the primary reason for your appointment today?
If applicable, how long has this been a concern(s)?
If applicable, what treatment has your pet received for current medical concern(s)?
What other medical or behavioral concerns do you have (related or otherwise)?
Anything else that you would like us to be aware of regarding your pet?
