Pre-Visit History Form - Reptile / Amphibian

Your Full Name *

First Name Last Name

What is the date of your appointment?

Date

Who is your pet's appointment with? *

Your Pet's Name *

Please confirm your email address *

example@example.com

Cell Phone Number *

Area Code Phone Number

Husbandry:

What species / breed is your pet? *

Where did you purchase / adopt your pet?

How old was your pet when you purchased / adopted?

Are you the pet's first owner? *

Yes No

Do you have other pets in your home? If so, what type(s), are they caged, and do they have contact with this pet.

Where does you pet live? *

Indoor Outdoor Both indoor and outdoor

Describe cage: size, shape, material, floor (solid / wire), location?

If possible, please upload a photo of the habitat / enclosure.

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What type of bedding / substrate? Changed how often?

What type of lighting? Type of bulb(s), wattage, enclosure, location, last replaced, on timer?

What type of room / window lighting? How many hours of light is pet exposed to in the room?

Heat source(s): bulb, heating pad / rock, on all the time?

Heat gradient (hottest and coolest temps) in cage? Day vs. night? How is this monitored?

Typical temperature range of room in which cage is kept? Does this change seasonally?

How is water provided? Bowl, dripper bottle, changed how often, what type of water?

Is humidity level in cage monitored? How?

Do you soak / bathe your pet? Describe process, frequency.

For aquatic species: Any water treatments? Water source and how often changed? Is a filtration system in use, describe? Is a heater in use? Water temperature range?

Cage furniture: houses, hides, rocks, logs, toys, other? Cleaned when / how?

Diet: Amount / frequency / brand of hay, pellets, vegetables, fruits, treats, other?

Insectivore / Carnivore: What type of meat / prey? Live, frozen, dehydrated? How much / how often? Purchased where? If live prey are they dusted / gut loaded with multivitamin?

Medications / supplements: Brand, dose, frequency, last given?

Socialization / handling: Who cares for the pet? Favorite person? How much time out of cage on average, is this observed or unobserved? Grooming / play? Time outdoors, describe?

Medical History:

What brings you in today? *

Wellness visit Medical visit

Symptoms: Onset, duration, severity, progression, other pets or people affected?

Has there been a change in the diet, cage, surroundings (home), cage mates, caretaker, or routine that may have caused the onset of symptoms?

Possible trauma, toxin, ingestion of atypical food, exposure to smoke / fumes / chemicals?

Changes in: Appetite, drinking, urination, feces / droppings? Describe:

Any measured or suspected weight gain / loss?

Changes in: activity level or behavior / routines? Describe:

Changes in respiratory rate, effort, or sound?

Changes in coat? Lesions, hair loss, itching?

Changes in mobility, limping, suspected pain when handled? Describe:

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Reptile / Amphibian Medical History