Reptile Patient History
Name
*
First Name
Last Name
Pet Name
*
Date
*
-
Month
-
Day
Year
Date
Species / Breed
*
Color
*
Age / DOB
*
Actual
Estimate
Sex
*
Female
Male
Unknown
How long have you owned your reptile?
*
Where did you acquire your reptile?
*
Any previous health concerns?
Any history of egg laying?
When?
-
Month
-
Day
Year
Date
Any problems with egg laying?
Have you or your bird been in contact with any other pets within 30 days?
Yes
No
What type of cage is your reptile housed in?
Is the cage located
indoors
outdoors
How long does your reptile spend in cage?
How long does your reptile spend outside of cage?
Where is the cage located?
Dimensions of cage - approximate
How often is cage changed / cleaned?
*
Daily
Weekly
Monthly
What type of cleaning chemical is used?
*
What type of accessories are in the cage?
*
What temperature is the inside of the cage kept?
*
How do you measure the temperature?
*
What humidity level is the inside of the cage?
*
How is the humidity level measured?
*
What is the heat source?
*
Is there a UVA/UVB light present?
*
Yes
No
Date of purchase
*
-
Month
-
Day
Year
Date
What do you feed your reptile?
*
What brand of food do you feed?
How often do you feed your reptile?
*
Does your reptile receive any supplements or treats?
*
Yes
No
Type of Supplements or treats?
Do you supplement with Calcium?
Yes
No
What type of calcium do you use?
What type of water does your reptile receive?
*
Tap
Purified
How often is food or water changed?
How often are the food dishes washed?
What type of soap/disinfectant is used?
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