Avian, Exotics, and Zoological Care Patient History Form

Phone

This field is for validation purposes and should be left unchanged.

Basic Information

Date of Appointment(Required)

If you have not yet scheduled an appointment with the avian, exotics, and zoological medicine service, please call (970) 297-5000 to schedule your pet’s appointment before completing this form.

Owner's Name(Required)

First Last

Phone(Required)

Email(Required)

Pet's Name(Required)

First

Pet's Date of Birth(Required)

Type of Animal(Required)

Sex(Required)

Male

Female

Unknown

Has she ever given birth?(Required)

Yes

Has she ever laid eggs/given birth?(Required)

Yes

Has she ever laid eggs?(Required)

Yes

How many pregnancies?(Required)

Please enter a number less than or equal to 25.

When was the last time she laid eggs?(Required)

Were the eggs normal?(Required)

Yes

Describe how they were abnormal:(Required)

Spayed/Neutered?(Required)

Yes

Species(Required)

Breed(Required)

Origin

Where was your pet obtained?(Required)

How long has your pet been in your care?(Required)

Health

Please describe the reason for your visit:(Required)

Has your pet ever seen another veterinarian?(Required)

Yes

Name of veterinarian and/or clinic:(Required)

Has your pet had any previous health concerns?(Required)

Yes

Please describe:(Required)

Is your pet currently administered any medications?(Required)

Yes

Current Medications(Required)

Only list what you are currently giving. Example: Rimadyl, 75mg, once daily, oral. Click the plus icon (+) on the right to add a row.

Name of medication

Dose

Frequency of administration

Route

Enclosure/Cage

Describe your pet's enclosure:(Required)

Please include dimensions, what it is made of (sides, bottom, and top), where the enclosure is located in your home, and a description of everything in the enclosure (ex: enclosure furniture, such as hiding areas, substrate/litter, food and water dishes). You may also upload a photo of your pet’s enclosure below.

Please describe how the enclosure is cleaned, what cleaning products are used, and how often:(Required)

Upload Photo

You may upload a photo of your pet’s enclosure.

Max. file size: 50 MB.

Temperature

Do you provide a heat source for your pet?(Required)

Yes

Type of Heat Source(Required)

Basking lamp

Flood light

Ceramic heat bulb

Under tank mat

Describe where these heat sources are located:(Required)

What are your pet’s daytime temperatures in the basking area, and on the warm side and cool side of the enclosure?(Required)

What are your pet’s nighttime temperatures in the warm side and cool side of the enclosure?(Required)

How are these temperatures measured?(Required)

Which type of thermometer is used?(Required)

Digital

Analog

What is the normal ambient temperature where your pet is normally kept?(Required)

Do you provide any supplemental heat sources?(Required)

Yes

Please describe:(Required)

Lighting

Does your animal have access to a UVB bulb?(Required)

Yes

Describe the type of UVB bulb, where it is located in the enclosure, and its distance from your pet:(Required)

How often do you change the UVB bulb?(Required)

Is your pet given access to any other types of lighting?(Required)

Yes

Please describe:(Required)

What time does your pet go to bed at night?(Required)

What time does your pet wake up in the morning?(Required)

Is the enclosure covered at night?(Required)

Yes

Please describe the cover?(Required)

How many of your pet’s sleeping hours consist of it being in a completely dark and quiet area?(Required)

Please enter a number less than or equal to 24.

Are any supplemental lighting sources used?(Required)

Yes

List the type of light, how many hours it is on, and how frequently it is changed:(Required)

Humidity

Do you measure humidity in your pet’s environment?(Required)

Yes

Please state what the percentage is, how it is provided, and how it is measured:(Required)

Diet

What does your pet eat?(Required)

Don’t forget treats and supplements! Include everything that enters into your pet’s mouth as an edible item please. Click the plus icon (+) on the right to add a row.

Type of food, treat, or supplement

Frequency

Quantity

Are live insects fed?(Required)

Yes

Do you gut load them?(Required)

Yes

What is used for gut loading? How long are the insects gut loaded before feeding to your pet?(Required)

How is your pet offered water? How often is the water changed?(Required)

Describe your pet's water and food dishes, including shape and size:(Required)

Enrichment

Is your pet offered toys?(Required)

Yes

Describe the types and numbers of toys:(Required)

Does your pet spend time outside its enclosure?(Required)

Yes

For how long, how often, and how is this time spent?(Required)

Other Pets

Are there any other pets in the house?(Required)

Yes

List and indicate if there are any interactions or direct contact between these pets and the pet for which you scheduled an appointment.(Required)

Do you use any Teflon-containing materials in your home (non-stick pans, a self-cleaning oven, or space heater)?(Required)

Yes

Do you have any scented products (candles, perfumes, scented detergents, cigarette smoke, etc.) in your home?(Required)

Yes

Search

Avian, Exotics, and Zoological Care Patient History Form

Patient history form

Basic Information

Origin

Health

Enclosure/Cage

Temperature

Lighting

Humidity

Diet

Enrichment

Other Pets