Rabbit and Rodent History Form Rabbit and Rodent History Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Owner Personal InformationName *FirstLastEmail *Patient InformationSpeciesGenderMFUnknownSpayed/NeuteredYesNoUnknownDate of birthDate acquiredSource (pet store, breeder, previous owner)Number of previous owners (other than breeder, store)What states and/or countries has your pet lived in?EnvironmentIs the animal kept indoors or outdoors?:IndoorsOutdoorsDescribe the cage enclosure (size, type, objects in cage - dust bath, toys, etc.)What type of material is used to line the bottom of the cage/litter pan?Is the animal kept in the cage with other animals?YesNoHow much time does your pet spend outside of the cage?Is your pet supervised when it is out of the cage?At all timesSometimesNoDoes your pet chew on carpet or other objects/materials when outside of the cage?Please list recent changes in the environment, if anyDiet What amount of your pet’s diet consists of the following (please describe what the animal actually eats, not what is offered)Amount of hay (timothy, alfalfa, etc.)Amount of pellets (timothy, alfalfa, etc.)Amount of seeds (type/brand)Amount of vegetables (types)Amount of fruits (types) your (if toys, Other: Amount/typeHow often do you change your pet’s food?What (if any) treats do you give your pet (brand and amount)?Do you supplement your pet with any vitamins? Is the food or water supplemented with vitamins?YesNoPlease describe any recent change to your pet’s dietReproductiveHas your pet been bred before? If yes, how many times?YesNoDo you plan on breeding this pet in the future?YesNoMaybeIs your pet here for aCheck-upIllnessIs your pet’s activity levelNormalDecreasedIncreasedIs your pet’s appetiteNormalDecreasedIncreasedHave you noticed any of the followingWeight lossWeight gainDischarge from the eyes or noseIncreased breathing rate or effortA change in the droppingsAn increased or decreased thirstWeaknessCecotropes (Rabbits)Previous ConditionsHas your pet had any previous conditions, operations, or problems (including dental or gastrointestinal problems)?MiscellaneousIs your pet currently on any medications?:YesNoHas your pet been on any medications recently?YesNoIs there anything else you would like done today?YesNoAre there any additional questions you have for the doctor?Upload Photo Click or drag a file to this area to upload. Submit Now
