Reptile History Form

Reptile History Form
RDVM info
Species
Age:
Sex:
Background Information
Length of time owned:
Where was the animal acquired? (Breeder, pet store, other)
Wild-caught/Captive Bred?
Deparasitized? Yes/No; if yes, with what?
How often is pet handled? (Daily, occasionally, or never)
Animal ever taken outside? Yes/No; if yes, for how long?
When was last shed?
Any trouble shedding? Yes/No; If yes, specify:
Fecal consistency?
Husbandry
Type of enclosure:
Size of enclosure:
Where is cage located?
Cage furniture:
Cage substrate?
Frequency of cage cleaning?
Type of disinfectant used to clean cage?
Cage Environment:
Light cycle:
Heat source:
Type of Lighting:
Humidity level:
Temperature within cage (minimum, maximum, and basking area):
Nutrition
Type of food offered:
Amount fed/frequency:
When last fed:
Water source:
Any other pets? Yes/No; if yes, specify:
Any other reptiles? Yes/No; if yes, specify:
Reptiles are housed together or singly?
If not housed together, where are other reptiles located?
Any new additions to the reptile population? Yes/No; if yes, specify:
Past Medical History/Problem:
Current Presenting Problem:
Duration of Complaint:
I acknowledge that I have received the Reptile-Associated Salmonellosis Information handout.

(found as PDF file on forms page)
Name

First NameLast Name
Pet's name
Date

MonthDayYear
Date
Should be Empty:

Background Information