REPTILE & AMPHIBIAN HISTORY FORM

REPTILE & AMPHIBIAN HISTORY FORM

A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about you can discuss it in more depth with the veterinary staff during your appointment.
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
ANIMAL DETAILS
Reptile Name or Identification: *
Common or Scientific Name: *
Date of Birth *
Sex *

Male Female
Fixed *

Neutered Spayed Unknown
Origin *

Captive Bred Wild Caught Import Unknown
How Long Have You Had This Animal? *
From Where Did You Obtain This Animal? *
Does This Reptile Have A Reproductive History *

Yes No
Please Give Details:
When Did Your Reptile Last Shed? *
How Often Has Your Reptile Been Shedding? *
Do You Have Other Reptiles Or Pets? *

Yes No
Please Give Details:
Have You Or Your Reptile Had Any Contact With Other Reptiles In The Last 30 Days? *

Yes No
Please Give Details:
When Was The Last Reptile Added To Your Collection? *
REASON FOR PRESENTATION TODAY
What Is The Primary Complaint Or What Signs Have You Noticed? *
How Long Have These Problems Been Present? *
What Health Problems Has Your Reptile Had Previously? *
Has Your Reptile Received Any Treatment In The Last 30 Days? *

Yes No
If Yes, Please Give Details (What Was Used, Dosage, How Often, Duration)
Have You Noticed Any Change In Your Reptile's Behavior? *

Yes No
If Yes, Please Give Details
Have Any Other Animals Or Persons In The Household Had Any Illness In There Last 30 Days? *

Yes No
DIET
How Often Do You Feed Your Animal? *
Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):
Seed Mixtures: Yes/No* . Brand: blanks*. Amount: blank*.
Pellets: Yes/No* . Brand: blanks*. Amount: blank*.
Fruits and/or Vegetable: Yes/No* . Type: blanks*. Amount: blank*.
Flowers: Yes/No* . Type: blanks*. Amount: blank*.
Crickets: Yes/No* . Amount: blank*.
Dubia Roaches: Yes/No* . Amount: blank*.
Hornworms: Yes/No* . Amount: blank*.
Mealworms: Yes/No* . Amount: blank*.
Waxworms: Yes/No* . Amount: blank*.
Other Insects:
Rodent Types (Frozen/Thawed, Freshly Killed, Live Prey, Other)
Mice: Yes/No* . Type: blanks*. Amount: blank*.
Rats: Yes/No* . Type: blanks*. Amount: blank*.
Birds: Yes/No* . Type: blanks*. Amount: blank*.
Fish: Yes/No* . Type: blanks*. Amount: blank*.
Do You Feed Any Wild Animals To Your Animal? *
Any Other Food Items Fed? Please Give Details *
Do You Use Any Nutritional Supplements? *

Yes No
If Yes: What, How Much, & How Often?
Calcium With Vitamin D3, Calcium Without D3, Multivitamin
What Water Supply Do You Provide? *

Tap Water Bottled Water Rain/River Water
How Is The Water Provided? *

Bowl Dripper System Spray
How Often? *
How Often Is The Water Changed? *
Do You Use Water Supplements? *

Yes No
Please Give Details: *
Have You Noticed Any Changes In Feeding Or Drinking Behavior? *

Yes No
Please Give Details: *
Have You Noticed Any Changes In Droppings (Fecal Material, Urine and Urates)? *

Yes No
Please Give Details: *
CAGE ENVIRONMENT
What Type Of Cage Is Used? *

Arboreal (Tall, Climbing) Terrestrial Aquatic
Cage Size: *
Substrate: *
What Is The Cage Made Of? *

Plastic/Fiber Glass Wooden Metal Glass Other
Please Explain If Other: *
What Decor & Furnishings Are Present? *
Is There Additional Ventilation? (Grills Or Mesh) *

Yes No
Please Give Details: *
Are Bathing/Spraying Facilities Provided? *

Yes No
Please Give Details: *
Where Is The Cage Located? *

Inside Outside
How Often Is The Cage Cleaned? *
What Cleaning/Disinfectant Agents Are Used? *
Please Give Details: *
What Heating Equipment Is Used?

Ceramic/Infrared
How Much Power In Watts? (__W)
Thermostat Control?

Yes No
Spotlight/Bulb
How Much Power In Watts? (__W)
Thermostat Control?

Yes No
Heat Mat
Size:
Thermostat Control?

Yes No
Location Of Heat Mat?

Under Cage Inside Cage
Other Heaters, Please Give Details: *
Are The Heat Sources Screened From The Animal(s)? *

Yes No
Please Give Details: *
Can The Animal(s) Touch Or Access The Heat Source? *

Yes No
Please Give Details: *
Is There Additional Lighting Provided Inside The Cage? *

Yes No
If Yes, What Type Of Light Is Used?

Light Bulb Fluorescent Strip Light
What Is The Model & Manufacturer?
When Was The Light Last Replaced?
Are The Lights Screened From The Animal(s)? *

Yes No
Please Give Details: *
Can The Animal(s) Touch Or Access The Light Source? *

Yes No
Please Give Details: *
How Many Hours Of Light Are Provided Each Day? *
Is There Ever Access To Direct Sunlight? (Not Through Glass Or Plastic) *
If Yes, How Many Hours Per Day Or Per Week?
Do You Measure The Humidity In The Cage? *

Yes No
If Yes, What Is The Humidity Level?
What Are The Daytime Temperatures? Hottest Area: Yes/No* . Basking Area: blanks*. Coolest Area: blank*.
What Are The Nighttime Temperatures? Hottest Area: Yes/No* . Basking Area: blanks*. Coolest Area: blank*.
Is The Animal Supervised When Out Of The Cage? *

Yes No
Does Anyone In The Household Smoke? *

Yes No
Do You Use Any Aerosolized Products? *

Yes No
Have There Been Changes In The Animal's Environment In The Last 3 Months? *

Yes No
Please Give Details: *
IF AQUATIC
Aquarium Heater Wattage
Thermostat Control

Yes No
Filter Type

In Tank Hang On Filter Canister Other
Temperature Of Water:
Temperature Measured With Thermometer?

Yes No
How Often Water Quality Checked (Ammonia, Nitrates, Nitrites, pH)
Basking Platform?

Yes No
Water Conditioner?

Yes No
How Often Water Changes Performed?
Percentage Of Water Changed?
Any Other Comments Or Information:
Should be Empty:

REPTILE & AMPHIBIAN HISTORY FORM

ANIMAL DETAILS

REASON FOR PRESENTATION TODAY

DIET

CAGE ENVIRONMENT

What Heating Equipment Is Used?

IF AQUATIC