Rabbit and Guinea Pig History Intake Form
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Client Name *
Email *
Phone Number *
Patient Name *
Patient Age *
Appointment Date *
Where did you get your pet and how long ago? *
Does your pet have any exposure to and/or live with other animals? If yes, please list species and if they interact with each other. *
What are you currently feeding your pet?  Please list brand, how much and how often you are feeding per day. *
Do you give your pet any medications or supplements?  If yes, please list medication name, strength, and how often it is given. *
How do you house your pet and how often is their area cleaned?  Please include what type of litter/bedding you use. *
How is your pet’s appetite? *
Any soft stools or diarrhea? *
Has there been any change in your pet’s water intake or urination?  If yes, please list when the symptoms started, how frequent and descriptions. *
Any sneezing or changes in breathing? *
How is your pet’s energy level? *
Is your pet having any problems with lameness or stiffness?  If yes, please list when the symptom started, how frequent and descriptions. *
Is there anything in your pet’s history we need to be aware of?  Please list chronic issues, surgeries, irregular blood work, diagnoses and medical conditions. *
Do you have any concerns about your pet today? If yes, please explain. *
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