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Rodent History Form

"*" indicates required fields

Owner's First Name*

Owner's Last Name*

Phone Number*

Patient Name*

Age*

Sex*

Male

Female

Species*

Rat

Mouse

Breed*

Color*

Has your pet been to a veterinarian before?*

Yes

No

If so, where?*

Reason for your visit*

Wellness

Sick

Tell us more*

Tell us a little bit about what is going on with your pet.*

Please select all that apply

If other, please specify*

Your Pet's History

Where did you get your pet?*

Pet Store

Breeder

Private Party/Friend

Other

If other, please specify*

How long have you had your pet?*

Has your pet had any history of medical issues?*

Yes

No

If yes, please specify*

Is your pet currently on any medications, supplements, or preventatives?*

Yes

No

If yes, please list all medications, supplements, and preventatives*

Please list dosage and amount

Housing

What type of enclosure do you keep your pet in?*

What type of bedding do you use & how often is it changed?*

Where is the enclosure located?*

What types of toys/enrichment does your pet have in their enclosure?*

Are there any other pets in your home that have contact with your rodent?*

Diet

What type of food(s) do you offer?*

Amount fed*

Have there been any recent changes in diet?*

Yes

No

If yes, please describe*

What type of water do you provide?*

Sipper/Drip bottle

Bowl

How often is the water source cleaned?*

A Day in the Life

What does a day in your rodent's life look like?*

Are they allowed to roam the house? Supervised or unsupervised?

Is there anything else you'd like us to know about your rodent?*

Signature*

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