Small Mammal Pre-Examination Checklist Owner’s Full Name: First Last Date MM slash DD slash YYYY Pet’s Name:Pet’s Age:Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail Address REASON FOR TODAY’S VISIT:What do you feed your pet?How Much?How Often?Nutritional Supplements?Has your pet eaten today? Yes No What?What Time?Does your pet have any allergies or vaccine reactions? Yes No To What?Do you use any flea/tick preventative? Yes No What kind?Date last administered?_ MM slash DD slash YYYY Does your pet go outside?Type of caging and bedding used?Where is the cage kept?HAS YOUR PET SHOWN ANY OF THE FOLLOWING SYMPTOMS:Weight gain Yes No DescriptionWeight Loss Yes No DescriptionAppetite Increase Decrease DescriptionDiarrhea Yes No DescriptionConstipation/Difficult Defecation Yes No DescriptionIncreased Drinking Yes No DescriptionIncreased Urination Yes No DescriptionHouse Soiling: incontinence (dribbling urine) Yes No DescriptionStool Yes No DescriptionBad Breath Yes No DescriptionDrooling Yes No DescriptionDifficulty Chewing Yes No DescriptionCoughing Yes No DescriptionSneezing Yes No DescriptionWheezing Yes No DescriptionTrouble Eating Yes No DescriptionUncoordinated Yes No DescriptionLameness Yes No DescriptionStiffness Yes No DescriptionDecreased Activity Yes No DescriptionListlessness Yes No DescriptionWeakness Yes No DescriptionMuscle Tremors Yes No DescriptionShaking Yes No DescriptionSeizures Yes No DescriptionUnusual discharges Yes No DescriptionBody Odors Yes No DescriptionScooting of the rear end Yes No DescriptionHead Tilts Yes No DescriptionEar Scratching/rubbing Yes No DescriptionIncrease of Grooming Yes No DescriptionDecrease of Grooming Yes No DescriptionItching Yes No DescriptionScratching Yes No DescriptionPoor Coat Yes No DescriptionHair Loss Yes No DescriptionChange in Behavior Yes No DescriptionSkin problems Yes No DescriptionLumps or bumps Yes No DescriptionANY OTHER PROBLEMS OR CONCERNS? Yes No DescriptionI Hereby authorize SUFFIELD VETERINARY HOSPITAL to preform professional services as are in their opinion necessary and advisable for treatment and maintenance of my pet’s health and well being.I also authorize SUFFIELD VETERINIARY HOSPITAL to perform the following, if deemed necessary: Bloodwork X-rays Sedation I Understand professional service are to be paid at the time they delivered.I will satisfy payment by the following method: Cash Check Master/Visa/Discover/AMEX The number where I can be reached today is:I am the owner or agent of the aforementioned animal, am at least 18 years of age, and am competent to contract in my own name. I have read this document in its entirety before signing below and I fully understand all of the content in this document and its meaning. I fully understand the impact of signing this release.SignaturePRINTED NAME:DATE: MM slash DD slash YYYY
