Belleway Veterinary Hospital

6833 Hwy 62, RR 5 Belleville , Ontario K8N 4Z5

(613) 969-0537

Rabbit & Rodent History Form

Date: ___________________

Instructions: An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information. Plaese check the appropriate boxes or use the spaces provided. Thank-you.

1. Patient Information

Species: __________________

Gender: Male ____ Female ____ Unknown _____

Spayed/Neutered (Y, N, or Unknown) ____

Date of Birth: _______________

Date acquired and source (pet store, breeder, previous owner): ______________

Number of previous owners (other than breeder, store): ____

What states and countries has your pet lived in? ____________________________

2. Environment

Is the animal kept indoors or outdoors? ____________________

Describe the cage enclosure type, size, objects in the cage (dust baths, toys, etc.)

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What material is used to line the bottom of the cage/litter pan?

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Is the animal kept in a cage with other animals (Y or N)? ____

If you answered YES to the previous question, how many cage-mates are there? What sex are the cage-mates? Are the cage-mates spayed/neutered?

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Please list all other pets in the household ___________________________________

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Have there been any new pets (within the past six months) placed in this animal's cage? _________________________________________________________

How much time does your pet spend outside of the cage? __________________

Is your pet supervised when it is out of the cage?

____ all times ____ sometimes ____ No

Does your pet chew on carpet or other objects/materials when outside of the cage? ________________________________________________________________

List recent changes in the environment, if any: ________________________________________________________________________

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3. Diet

What amount of your pet's diet consists of the following (please describe what the animal actually eats, not what is offered):

Amount of Hay (Timothy, Alfalfa, etc.) ______________________________

Amount of Pellets (Timothy, Alfalfa, etc.) ______________________________

Amount of Seeds (type/brand) ______________________________

Amount of Vegetables (types) ______________________________

Amount of Fruits (types) ______________________________

Other: __________________ Amount & Type: ____________________

How often do you change your pet's food? ________________________________

What (if any) treats do you give your pet (brand and amount)? _______________

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Do you supplement your pet with any vitamins? Is the food or water supplemented with vitamins? Brand and frequency?

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Please describe any recent change to your pet's diet. ______________________

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4. Reproductive

Has this pet been bred before? If yes, how many times? ____________________

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When was it last bred? ___________________________________________________

What was the size of all previous litter(s)? Was the litter healthy? _______________

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Do you plan on breeding this pet in the future? _____________________________

5. Is your pet here for a well pet check-up ____ or is it sick ____

(check one)?

If your pet is sick, please describe the signs and how long your pet has been showing these signs: _____________________________________________________

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Is your pet's activity level normal _____, decreased ____, or, increased ____ ?

Is your pet's appetite normal ____, decreased ____, or, increased ____ ?

Have you noticed any of the following?

__ weight loss

__ weight gain

__ discharge from the eyes or nose

__ a change in the droppings

__ an increased or decreased thirst

__ weakness

6. Previous Conditions:

Has your pet had any previous condiitons, operations or problems (including dental or gastrointestinal problems?) ____________________________________

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7. Miscellaneous

Is your pet currently on any medications? ________________________________

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Has your pet been on any medications recently? If yes, please list them. ____

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8. Is there anything else you would like done today?

__ Nail trim

__ Have questions about: _____________________________________________

__ Other: ____________________________________________________________