Reptile/Amphibian History Form

Date

Name

First NameLast Name

Pet's Name:

Species/Breed (if known):

What is the primary reason for your visit and what concerns do you have today?

Has your pet received any treatment at home? What was given, and how long was it given?

Has your pet been seen at another clinic? If so, please list the clinic name so we can call for records.

The following questions are regarding the husbandry, or at home living environment of your pet. This information helps us get a full picture of what may be going on with your pet.

How old is your pet?

How long have you had your pet?

Where did you get your pet from?

What is your pet housed in (i.e. tank, turtle table, custom built enclosure, etc.)?

Please email or upload pictures of your pet’s enclosure.

Browse Files

What is the size of your pet’s enclosure (L x H x W)?

Where in the house is your pet primarily living (i.e living room, garage, bedroom)?

Is the enclosure near vents/windows/outside walls?

YesNo

How much time does your pet spend outside of the enclosure?

What substrate (bedding) do you use in the enclosure?

How frequently do you spot clean and fully clean the enclosure?

How often do you clean the food and water dishes?

What do you use to clean the enclosure and dishes?

What kind of hides and enrichment are in the enclosure (i.e. hammocks, plants, hides, blankets, etc.)?

What do you primarily feed your pet (i.e. pellets, fruits/veggies, crickets, mice/rats, etc.)? Please list brands/sources if known.

How much and how often do you feed your pet?

What treats do you give your pet? How often?

Do you feed in the enclosure or out of the enclosure?

Do you use vitamin or mineral supplements? If so, what kind and how often?

If feeding insects, do you gut load the insects?

What is the maximum and minimum temperature in the enclosure?

Does pet have a basking spot?

YesNo

What is the maximum and minimum humidity in the enclosure?

How many hours of daylight and nighttime does your pet get each day?

Please describe all lights used in the enclosure (i.e. fluorescent, incandescent, red lights, etc.).

Do you use a UVA/UVB light for your pet?

YesNo

What is the heating source for your pet (i.e. ceramic bulb, under tank heater, etc.)?

Has your pet ever laid eggs before?

YesNo

Are there any nesting areas in the enclosure?

YesNo

Are there any other pets that share the same enclosure with this pet?

Are there any other pets in the house?

How often does this pet interact with the other pets?

For water animals:

How often do you test the water quality?

What do you use to measure the water quality?

Do you feed pet in the primary living tank, or out of the primary living tank?

What water additives, if any, do you use?