Small Mammal Pre-Examination Checklist Owner’s Full Name: First Last Date 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?YesNoWhat?What Time?Does your pet have any allergies or vaccine reactions?YesNoTo What?Do you use any flea/tick preventative?YesNoWhat kind?Date last administered?_ 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 gainYesNoDescriptionWeight LossYesNoDescriptionAppetiteIncreaseDecreaseDescriptionDiarrheaYesNoDescriptionConstipation/Difficult DefecationYesNoDescriptionIncreased DrinkingYesNoDescriptionIncreased UrinationYesNoDescriptionHouse Soiling: incontinence (dribbling urine)YesNoDescriptionStoolYesNoDescriptionBad BreathYesNoDescriptionDroolingYesNoDescriptionDifficulty ChewingYesNoDescriptionCoughingYesNoDescriptionSneezingYesNoDescriptionWheezingYesNoDescriptionTrouble EatingYesNoDescriptionUncoordinatedYesNoDescriptionLamenessYesNoDescriptionStiffnessYesNoDescriptionDecreased ActivityYesNoDescriptionListlessnessYesNoDescriptionWeaknessYesNoDescriptionMuscle TremorsYesNoDescriptionShakingYesNoDescriptionSeizuresYesNoDescriptionUnusual dischargesYesNoDescriptionBody OdorsYesNoDescriptionScooting of the rear endYesNoDescriptionHead TiltsYesNoDescriptionEar Scratching/rubbingYesNoDescriptionIncrease of GroomingYesNoDescriptionDecrease of GroomingYesNoDescriptionItchingYesNoDescriptionScratchingYesNoDescriptionPoor CoatYesNoDescriptionHair LossYesNoDescriptionChange in BehaviorYesNoDescriptionSkin problemsYesNoDescriptionLumps or bumpsYesNoDescriptionANY OTHER PROBLEMS OR CONCERNS?YesNoDescriptionI 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:CashCheckMaster/Visa/Discover/AMEXThe 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:
