Rabbit and Guinea Pig History Intake Form

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Client Name *

Email *

Phone Number *

Please list previous veterinary hospitals for records. Put "N/A" if not applicable.
*

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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