Exotics Questionnaire

Client's Name: *

Phone #: *

Email address: *

Address: *

City: *

State: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Pet's Name: *

Pet Type:
Small mammal
Bird
Reptile

What prompted you to bring your pet in today?
Wellness
Nail trim
Injury
Other

How was your pet acquired?
Store
Rescue
Previous Owner
Breeder
Other

In years, how long ago was your pet acquired?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

In years, how old is your pet?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Is this age exact or an estimate?
Exact   Approximation

Please check whichever applies:
This is my only pet
My pet shares an enclosure with other pet(s) of the same type
My pet interacts with other pets of the same type in my household but does not share an enclosure
There are other pets of this type in my household, but they are kept apart/in separate areas

Please describe your pet's habitat as best as possible:

Enclosure size and type:

Location within the home:

Enrichment/toys offered:

Types of bedding/litter/substrate:

Frequency of enclosure cleanings:

Does your pet have any exposure to unfiltered UV light (not through a window)?
No UV exposure
Time spent outdoors
UV light over enclosure

If you have a UVB bulb, how often do you change it?

Please check whichever applies in regards to how your pet spends time in a cage/enclosure:
My pet is almost always in its enclosure
My pet spends supervised time out of enclosure
My pet spends unsupervised time out of enclosure

Please describe your pet's diet and amounts, including any people food, treats, etc.:
(Please use brand names if possible.)

What supplements, vitamins or medications is your pet currently taking?

Do the droppings appear normal? If no, please describe what has changed:
Normal Not normal
If not normal please describe:

Do you bathe your pet or soak your reptile?
Yes No

If so: How often?
Daily
Weekly
Monthly
Bimonthly
Quarterly
Semi-annually
Annually
As needed
Never
Other

What do you use?

Is there anything in your pet's previous medical history that we should be aware of?
(ex: illnesses, injuries, hospitalizations, allergies, egg laying, etc.)

For Reptiles Only

Describe any heating/light elements you use, and how you use them during the day and at night.

How do you measure temperature and humidity within your reptile's enclosure?

If known, what are the parameters inside the enclosure?
(for example, is the temperature on the cool side or warm side, humidity, coolest night temperature, etc.)

For Birds Only

Is your bird flighted or non-flighted currently?
Flighted Non-flighted

How has your bird's gender been determined (if at all)?
Sexual dimorphism
DNA sexing
Egg laying
Has not been reliably determined

If sexed, Male or Female?
Male Female Unknown

If you have noticed any behavioral changes to your bird recently or have previously been seen by a Veterinarian for behavioral issues, please describe:

How long have the behaviors listed above been occurring, and how frequently?

Have any of the behaviors noticed changed in duration, intensity, or frequency over time?

Is there anything specific that you've noticed relating to when the behaviors occur? (ex: when you leave the house, only at night, seasonal, only around a certain person, etc.)

When your bird is engaging in these behaviors, how have you been responding?

Have you tried any treatments or made any changes in an attempt to correct any of the behaviors listed? If yes, what did you try? How effective did you feel the change/treatment was?

Egg Laying for Birds and Reptiles

How long has it been since your bird or reptile laid an egg for the first time?

How frequently does your bird or reptile lay eggs, and when was the last time she laid one?

Has your bird or reptile ever had a difficult time laying eggs? If so, please explain the issue: (ex: straining, blood present, prolonged recovery, etc.)

To the best of your knowledge, have the eggs always looked like they were of normal size, shape, and thickness? If no, please explain what you noticed:

Check the box below