Reptile/Amphibian History Form

Date

Month Day Year
Date
Name

First Name Last Name
Pet's Name:
Species/Breed:
Please describe all light and heat sources in the enclosure.
Reptile/Amphibian History Form
How long have you had this pet?
Where did this pet come from?
Do you have any other reptiles/amphibians/pets?

Yes No
If so, please list each pet and how long you have owned them.
What type of substrate is used in the habitat?
How frequently is the substrate changed?
How frequently is the entire habitat cleaned?
How often are the food and water dishes cleaned?
What type of diet is fed?
Do you use vitamin or mineral supplements?

Yes No
If so, what type?
What is the maximum/minimum temperature/humidity in the habitat (daytime/nighttime)?
How often is your pet bathed/soaked/misted?
Where in the home is the primary habitat for your pet located?
Has your pet received any home treatments or veterinary care previously?

Yes No
If so, please explain. Include medication names, dosages and length of treatment.
Has your pet ever had labwork?

Yes No
If so, where was the labwork performed?
What is the primary reason for your visit today and what concerns do you have?
Should be Empty: