Reptile History Form

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...)
Should be Empty:

Reptile History Form

AQUATIC SPECIES

Artificial Lighting in enclosure/living space

Temperature

What percent of your reptile's diet consists of the following (please describe what the animal actually eats, rather than what is offered)