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Outpatient Medical History
Small Exotic Mammal Initial/Annual Visit Form
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*
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Owner:
*
First*
Last*
Pet's Name
Sex
Male
Female
Age
Previous Vet
Current Medications
Reason for Visit
Diet (fed vs eaten)
Amount Offered
Amount Eaten
Fresh Fruits (list all)
Fresh Vegetables (list all)
Insects
Meats (list all types)
Mixes/Home Cooked Meals (list all ingredients)
Treats (list all)
Source of Drinking Water
Bottled Water or Dish
Bottled
Dish
Vitamin and Mineral Supplements
Yes
No
In Water or Food?
Water
Food
Type of Vitamin and Mineral Supplements
Frequency Food is Changed
Frequency Water is Changed
Housing: Enclosure or Terrarium
Terrarium
Enclosure
What is Enclosure Made out of?
Type of Bedding
Frequency Bedding Changed
Disinfectant Used to Clean Enclosure
How Often Cleaned?
Is pet housed alone?
Yes
No
If no, how many other pets are housed with this pet?
Type of animals housed with pet?
Are there other pets in the household?
Yes
No
If yes, please list them:
Are any ill?
Yes
No
How often is your pet handled?
House is your pet exercised?
Frequency of exercise?
Does your pet go outside?
Never
50%
Always
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