Client Details

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Email Address

Chinchilla Details

Name

Age (date of birth)

Sex

Spayed/Neutered?

If neutered, please specify at what age

Date acquired

Source (pet shop, friend, breeder, etc)

Details of Other Pets

Do you have any other chinchillas? If yes, please provide details (name, age, date acquired, source, any known illness)

Do you have any other pets? If yes, please provide details (species, age, date acquired, source, any known illness)

Husbandry

Is your chinchilla kept in a cage? If yes, please provide approximate dimensions

Please describe the bedding used in the cage

Has your chinchilla damaged any household items? If yes, please provide details (item, how and when it was damaged)

Do you provide a dust bath for your chinchilla? If yes, what type of sand do you use?

Is your chinchilla allowed access to the outside or a garden? If yes, is this supervised?

Where does your chinchilla urinate and defecate?

Food

Please select all items he/she is known to eat in a given day

Pelleted diet
Fresh produce
Timothy hay
Alfafa hay
Other

If other, please specify

Please describe the quantities of these items

Has there been a recent change in diet? If yes, please specify

Are any of the following given to your chinchilla?

Vitamins
Minerals
Medicines
Probiotics

Water

Does your chinchilla drink from a bowl or a sipper-bottle?

Have there been any changes to your chinchilla’s drinking?

Has the drinking increased or decreased as of late? If yes, when did you notice?

General Info

Does your chinchilla dig or burrow?

Have there been any previous health issues with your chinchilla? (If yes, please provide details including dates)

The Presenting Health Concern

Please describe your chinchilla’s clinical symptoms

Have you noticed any of the following

Nasal discharge
Ocular discharge
Coprophagy (chinchilla eating droppings)

Are the droppings normal in appearance and size? If not, please specify

Does the skin and fur appear normal?

Has there been any excessive scratching?

Has there been any odd positioning or loss of use of any limbs? If yes, please specify

Has there been any abnormal vocalization?

Any additional comments

Chinchilla History Form

Client Details

Chinchilla Details

Details of Other Pets

Husbandry

Food

Water

General Info

The Presenting Health Concern

About Us

Regular Clinic Hours

Location

Directions