Owner Contact Information

Owner name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

First visit
Returning client (new pet)
Returning client/patient

Swine Information

Swine name *

Age

Birthday (if known)

Color Morph/Variation

Sex *

Male
Female
Unknown

Source of Swine *

Store
Breeder
Adoption/Rescue
Other

Describe *

Environment/Husbandry

Swine is kept in: *

Free in home/room
Pen/Enclosure Indoors
Pen/Enclosure Outdoors
Primarily indoor with supervised outside time

Other swine in the same enclosure or area? *

Yes
No

If yes, list names and genders: *

List other swine on the premises, past, or present:

Are any of those sick? *

Yes
No

if yes, give details:

Have any passed away? *

Yes
No

if yes, give details:

List other pets in the home or yard, including vaccination status:

List all toys and materials/substances available to swine (ex: carpet, hardwood, concrete, grass, etc):

What flooring substance is the swine usually on?

Frequency of cleaning swine environment:

Does the Swine use a litterbox?

Yes
No

If yes, what type of litter box do you use? *

Method and frequency of cleaning/changing food and water source:

Sleeping habits: *

Hours of darkness/quiet time:
In sleeping enclosure/crate
free choice of when to sleep/wake

Hours of darkness/quiet time: *

What is the current diet (Include brands of products):

Dry Food

Fresh Fruit/Veggies

Other (describe)

Volume of food offered:

Dry Food

Fresh Food

Free Feed

Other (describe)

How many times do you feed your pet daily?

Do you bathe your swine? *

Yes
No

If yes, what products do you use?

Do you use any grooming products? Ex: Brushes, combs, sprays, wipes. Please explain:

Medical History

Previous illnesses or injuries:

Previous medications:

Any current medications: *

Yes
No

If yes, describe:

Vaccination history: Rhini-Shield Vaccinated? *

Yes
No

If yes, date last given? *

Vaccination history: Rhini-Shield Vaccinated? *

Yes
No

If yes, date last given? *

History of vaccine reactions: *

Yes
No

If yes, to what? *

History of allergies: *

Yes
No

If yes, to what? *

Does your swine have tusks? *

Yes
No

If yes, do you get them trimmed and how often? *

Has your swine needed hoof trims before? *

Yes
No

If yes, how often? *

Date of last examination: *

Any previous medical records?

Do you use any monthly preventatives? *

Yes
No

If yes, what? *

Reproductive History

If female, any history of pregnancy or giving birth? *

Yes
No

If so, when was the last birth? *

How many pregnancies, if known?

How many kittens were born?

Any history of cesarian section (surgical removal of piglets?)

Yes
No

Behavioral History

Any behavioral issues:

Yes
No

Describe *

How long has it been an issue?

Any previous or current treatments for behavioral issues:

Any difficulties with aggression/biting?

Yes
No

Explain *

Current Health Status

Reason for visit: *

Wellness exam (New pet)
Wellness Exam (Return/Annual visit)
Illness/Injury Exam

If ill, describe signs and concerns: *

How long have problems been occurring? *

Has this swine been seen for this problem before by a veterinarian?

Yes (At AEAC)
Yes (another practice)
No

If seen at another practice, please name: *

Have you tried treatments prescribed by a veterinarian?

Yes
No

If yes, what? *

Was it helpful?

Yes
No

Have you tried any treatments at home?

Yes
No

If yes, what? *

Was it helpful?

Yes
No

Mark any of the following symptoms seen

Characteristics of droppings:

Formed
Diarrhea
Blood
Increased urine

Stool color

Other changes/abnormalities:

Has your swine ever had a dental/teeth cleaning? *

Yes
No

If yes, when *

Does your swine have a history of dental disease or other mouth related illness? *

Yes
No

If yes, explain *

Any other concerns:

Swine History Form