Westminster Veterinary Group
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Step 1 of 4
Date*
First Name*
Last Name*

Patient Information

A detailed history is essential to provide the appropriate veterinary care for your pet. Please complete this form as accurately as possible. If there is anything you are unsure about, you can discuss it in more depth with the veterinarian during your appointment.

Common or Scientific Species Name:
Gender*
Date of Birth?*
Date acquired?
Please answer:
Source (pet store, breeder, previous owner):
Number of previous owners (other than breeder, store):
What states and countries has your pet lived in?
Previous conditions, problems or operations (list with date, if known):
Step 2 of 4

Environment

Is the pet kept indoors or outdoors?
Describe the cage enclosure – cage type, size, objects in cage (dust baths):
What is on the bottom of the cage?
If so, what types are they and when were they acquired?
List any other pets:
Is your pet supervised when it is out of the cage?
Does your bird chew on walls, furniture or other household objects?
List recent changes in the environment (if any):
Please list any air fresheners, cleaning products, deodorizers, or insecticides that are used in the same room as your pet:
Please list possible toxins or irritants:
Step 3 of 4

Diet

What percent of your pet’s diet consists of the following (please list only the things the pet eats, not what is offered)?

Amount of Hay (Timothy, Alfalfa, etc):
Amount of Pellet (Timothy, Alfalfa, etc):
Amount of Vegetables (Timothy, Alfalfa, etc):
Amount of Fruits (Timothy, Alfalfa, etc):
Other foods:
How often do you change your pet’s food?
Please list any supplements used. How are they given and how often?
Treats – List type(s) and frequency:
Water source?
Please list any recent additions/changes in the diet:
Step 4 of 4

Today's Visit

What is your pet here for today?*
If sick, please describe the signs and how long the pet has been showing these signs:
Is your pet eating normally?
Have you used any medications from the pet store?
If yes, please explain:
Have you noticed any of the following:
Has your pet been seen by another veterinarian for any of the current problems?
If yes, please list the tests performed and medications given:
Are there any other concerns or questions?

Contact Info

Company

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