Reptile History Form
An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Pet's Name
Gender
Male
Female
Date of birth/hatch
Date acquired
How big was the reptile when you first acquired it
Source (pet store, breeder, previous owner, etc...)
Captive bred or wild caught
Number of previous owners other than the breeder, store
What other states and countries has your reptile lived in
Where is this reptile kept in the house
Cage type and size
What is on the bottom of the cage?
What types of hiding places are provided?
List species of live plants in the enclosure
Is there a soaking/swimming tub
Yes
No
Please describe any other furnishings
How often is the cage cleaned and what cleaning products are used
AQUATIC SPECIES
How often is the water changed
What type of filtration is used
Do you use a dechlorinator or any type of water treatment, if yes describe
Does your reptile receive sunlight? If yes, how many hours per week
Does sunlight pass through glass or plastic before reaching the reptile
Yes
No
Does not apply
Artificial Lighting in enclosure/living space
Incandescent ("screw-in" bulbs)
Yes
No
Wattage and hours per day
Fluorescent (tube bulbs)
Yes
No
Brand(s)
Hours/day
How often are the fluorescent bulbs changed
Temperature
Do you have thermometers in the cage
Yes
No
What is the temperature in the warmest part of the cage
What is the temperature in the coolest part of the cage
What devices are used to maintain the temperature
Hot rock
Heating pad
Warm heat
Heat light
Ceramic heater
Aquarium heater
Other
Describe if you selected other
Is there a thermostat
Yes
No
Is the temperature decreased at night
Yes
No
If yes, by how much
Is the cage misted
Yes
No
Is the humidity measured
Yes
No
If yes, indicate range
How much time does your reptile spend outside of the enclosure (average hours/day)
Is your reptile supervised when it is out
Always
No
Sometimes
Is supplemental heating provided outside of the cage
Yes
No
If yes, indicate type
Have you ever noticed your reptile eat any household objects
Yes
No
Is the reptile ever taken outside
Yes
No
If yes, describe
List recent changes in the environment if any
Does your reptile hibernate
Yes
No
If yes, please describe the duration, temperature and monitoring that you provide during hibernation
If you have acquired any new pets within the past 6 months, please provide species, date and source
Do you have other pets
Yes
No
If yes, please list
Are any of your other pets ill
Yes
No
If yes, please describe
What percent of your reptile's diet consists of the following (please describe what the animal actually eats, rather than what is offered)
Percentage Vegetables, Fruits
List types
Percentage, insects mealworms, etc
Are they gut loaded or dusted before feeding to your reptile? If yes, please describe
Percentage, rodents, chicks etc...
List types and source
Are they fed
Live
Killed
Both
Percentage, pellets, commercial diet or canned food
List types
Percentage of other, please describe
How often do you feed your reptile
Please list any supplements used, as well as how they are given and how often
Does your reptile eat anything other than its intended diet (cat's food, house plants, etc...)
How is water offered (dish, misting, drip system, etc...)
Please list any recent additions/changes in the diet or leave blank if does not apply
When was the last shed
Was it normal
Yes
No
If no, please describe
Do you plan on breeding this animal
Yes
No
Possibly
How many clutches/litters has this reptile produced
How many eggs/babies were laid
Were the offspring healthy
Yes
No
If no, please describe
Has your reptile ever had difficulty laying
Yes
No
If yes, please describe
Has your reptile ever been tested or treated for internal or external parasites
Yes
No
If yes, please describe (include dates and medications used)
Has your reptile had any other prior conditions, problems or operations (list with date, if known)
Is your reptile here for
A well pet check-up (no major health concerns) if so please skip to the last question
A sick/unhealthy evaluation with health concerns
If your pet is sick, please describe the signs and how long your pet has been showing these signs
Is your pet's general activity level
Normal
Decreased
Increased
Is your pet's appetite
Normal
Decreased
Increased
Have you noticed any of the following
Weight loss
Weight gain
Discharge from the eyes or nose
Increased breathing rate or effort
A change in the droppings
Abnormal skin color or shedding
Parasites on the skin or in the feces
Weakness
Have you used any medications from a pet store? If yes, describe
Has your reptile been seen by another veterinarian for any of the current problems
Yes
No
If yes, list when and provide the tests performed and medications given
Is there anything else you'd like done today? (Nail trim, have questions, etc...)
Submit
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