Small Rodent Health Questionnaire Form Owner’s Name Date MM slash DD slash YYYY Address Postal Code Phone numbers (home) (cell) (work) Email Emerg. Contact(other than immediate family): ph: Pet’s Name Breed Colour Sex Male Female Neutered Spayed Age or Birthday How did you acquire your pet ? What type of food do you feed and how much do you feed Rodent pellets % of dietSeed mix % of diet or cup/day Fruits & Vegetables cup/day Other Does you pet drink from a bottle or bowl? Does your pet use a litter box? How much time does your pet spend in its cage? How often do you clean your pet ’s cage? What do you use for bedding? Do you groom your pet ? (i.e. trim nails, brush fur)? How often? Does your pet have any contact with other pets/animals inside or outside of your home? Has your pet been to a veterinarian before? If yes, when/where? Does your pet chew on things that he/she should not chew on? Has your pet ever had his/her teeth trimmed? If yes, when/where? Has your pet had any wet, clumped fecal matter? How often do you notice it? Have you noticed any of the following; scratching flakey skin teeth grinding lumps or bumps runny eyes/nose size in fecal balls sneezing and/or coughing changes in behaviour changes in eating and/or drinking habits changes in urine or fecal ball production If yes to any of the above, when did you notice this? Do you have other health issues or concerns you would like to discuss with the veterinarian? PhoneThis field is for validation purposes and should be left unchanged.
