Exotic Patient Form Home » Exotic Patient Form Step 1 of 4 - Page 1 25% Client Name Patient Name Species Breed Sex Male Female Unknown If known, how was it determined? Is your pet spayed (female) or neutered (male)? Spayed Neutered Origin of pet (wild caught, breeder, pet store): Hand Raised YES NO Unknown Length of Ownership Age Band Number/Microchip EnvironmentCageSize of cage(s): Where is the enclosure housed? % of day confined to enclosure vs free roaming: How often is the cage cleaned? What is used to clean the cage? What substrate/bedding is used in the enclosure? Types of Perches (if applicable) How often are perches rotated? Enclosure Humidity (if applicable)What is the relative humidity of the enclosure? How is the humidity determined? Enclosure Temperature (if applicable)What is the temperature gradient of the enclosure?Day: What is the temperature gradient of the enclosure?Night: What is the temperature gradient of the enclosure?How is the temperature measured? What type of heat source is utilized? Bathing HabitsType of Light (check those that apply) Natural Fluorescent UVB Amount of exposure to each daily: When was the UVB bulb last changed (if applicable): Exposure to LightHow often is pet bathed? What is used to bathe pet? Other access/environments (Play perches, floor, tables, outside, vacation home, etc.) Are you aware of any exposure your pet may have had to the following (Please check all that may apply)? Teflon Cook Wear Smokers Strong Cleaning Agents Aerosols Other Other Enrichment (Please circle all that apply and elaborate on following lines): Foragers Shreddable Toys Puzzle Toys Target Training etc. Elaborate DietWhat food (including the brand) is the pet provided? Please list all foods offered. List percentages of each category, if possible (i.e. % commercial diet, % vegetables, % fruits, % prey items):What does the pet actually eat? Please list all food items that pet eatsHow are non-commercial food prepared (raw, cooked, etc.)Access to Fresh WaterHow frequently is water offered? How frequently are water bowls cleaned? If applicable, does pet have adequate space/water for soaking? ExerciseDescribe the amount and type of exercise your pet receives: Medical HistoryWhen and where was your pet last seen, prior to today? (Please have records sent to Heartland Veterinary Hospital) Has your pet had any vaccines? If yes, please list which vaccines, when vaccine was given, and how vaccine was obtained.If your pet currently on any medications? If yes, please list medications, dosage, frequency, route, and where medication was prescribed.For the Visit TodayWhat is the primary reason for your appointment today? If applicable, how long has this been a concern? If applicable, what treatment has your pet received for current medical concern(s)?What other medical or behavior concerns do you have (related or otherwise)?Anything else that you would like us to be aware of regarding your pet?Other Pets in the HouseholdSpecies: Age(s): Amount of contact between other pets and above patient: Any known diseases with any other pet(s) within the household: PhoneThis field is for validation purposes and should be left unchanged.
