exoticsinformation Date Date Format: MM slash DD slash YYYY Client Name*Phone*Patient Name*Type of Animal*ADDITIONAL QUESTIONS REGARDING COVID19:1. Have you or anyone in your household traveled either out-of-state or by plane within the past 14 days?YesNo2. Have you or anyone in your household experienced any cold or flu-like symptoms recently?YesNo3. Have you or anyone in your household tested positive for COVID19, or been exposed to anyone that has tested positive for COVID19?YesNo1. Reason for visit:*2. Duration of the problem:*3. Has your pet been treated for this problem?*YesNo4. If you answered yes, what treatment was given and how long ago, treating hospital name:5. Has your pet had any medical problems? Is your pet taking any medications? List all:6. If the problem is due to an injury, do you know the cause of the injury?7. How long have you had your pet?*Where did you get pet from?*8. How is your pet’s appetite?*NormalDecreasedNot EatingHow long?9. How is your pet’s activity level?*NormalLethargicOtherIf Other, please explain:How long?10. How is your pet’s stool?*NormalHardSoftDiarrheaHow long?11. How is your pet breathing?*NormalLaboredOpen MouthWheezingHow long? Has it been getting worse since you noticed?12. Is your pet coughing or sneezing?*YesNoHow long?13. Do your pet’s eyes appear normal?*YesNoIf no, please describe:How long?14. Does your pet’s nose appear normal?*YesNoIf no, please describe:How long?15. What do you feed your pet? Please list everything:*16. Do you give any supplements? Please list all:17. Describe your pet’s housing (cage, tank, etc.). Please list everything in pet’s environment (toys, bedding, what cage is made of, etc.):*18. Where does your pet live?*IndoorOutdoorBothIf both, what percentage indoor vs. outdoor?19. (If Applicable) Does your pet have a heat and/or light source? Describe type, how many hours used and age of bulbs:20. Are there any other pets in the house?*YesNoIf yes, describe:21. Are any other pets or persons showing signs of illness?*YesNoIf yes, describe:22. Where in the home is your pet’s cage located? Is it in front of or near a window or doorway?*23. What do you clean your pet’s cage with? How often do you clean it?*24. Does anyone in the house smoke?*YesNo25. Do you use any items that have a non-stick surface (Teflon, Silverstone)?*YesNo26. Do you use scented candles, plug-in air fresheners, etc.? Please describe:27. What is the source of your pet’s drinking water?*TapBottledOtherIf other, please describe:28. How often do you change your pet’s water?29. Do you allow your pet to roam freely around the house?*YesNoSupervised30. (If Applicable) Is your pet vaccinated? List all and when they were given:31. (If Applicable) Has your pet had any vaccine reactions in the past?YesNo32. Do you know the sex of your pet? How was the sex determined?Blood testProbeEgg LayingOtherIf other, please describe:33. (If Applicable) Is your pet spayed/neutered?*YesNoIf yes, when was it done?34. (If Applicable) Does your pet have a history of egg laying?YesNo35. Is your pet displaying any breeding behavior?*YesNo36. (If Applicable) How is your pets color?NormalDarkerLighter37. Is your pet on any flea control?*YesNo38. Is your pet itchy? If so, how itchy on a scale 1-10 (1=not at all, 10= up all night scratching/chewing)?*12345678910Any Additional Questions or Concerns:
