Personal
Owner's Name
Name of Pet(s)
Species
Age
Sex (M/F/Unknown)
How long have you been keeping this species of pet?
How long have you had this pet?

Medical
Purpose of visit
Previous Veterinarian (if any)
If illness, describe signs, duration,and severity:
Coughing (Y/N)
Sneezing (Y/N)
Vomiting (Y/N)
Diarrhea (Y/N)
Lameness (Y/N)
Scratching (Y/N)
List existing or previous medical conditions:
List any medications given

Diet
What food is offered and what is eaten? (Include brand names, frequency, and method of feeding)
Supplements or vitamins

Water
Dish or bottle?
How often is container refilled?
How often is container cleaned?

Housing
Size and type of cage
Type of bedding
Frequency of cleaning
Kept alone or with how many others?

Exercise
Please describe method and frequency of exercise

Handling
How often?
By whom?

Other
Any other pertinent information?