AQUATIC ANIMAL HISTORY FORM

AQUATIC ANIMAL 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 NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
FISH, INVERTEBRATES & TREATMENTS
Aquatic Name or Identification:*
Common or Scientific Name:*
Date of Birth*
Age*
Sex*

MaleFemaleUnknown
Origin*

Captive BredWild CaughtImportUnknown
How Long Have You Had This Animal?*
From Where Did You Obtain This Animal?*
REASON FOR PRESENTATION TODAY
What Is The Primary Complaint Or What Signs Have You Noticed?*
Do You Operate A Quarantine System?*

YesNo
If Yes, please Give Details:
What Other Species Are Present?*
Has Any Disease Been Diagnosed In ANY Fish Or This Tank Previously?*

YesNo
If Yes, please Give Details:
Have You Treated With Any Of The Following Products?
Formalin, Formaldehyde*

YesNo
If Yes, Please Give Details (Dosage & Response)
Potassium Permanganate*

YesNo
If Yes, Please Give Details (Dosage & Response)
Copper*

YesNo
If Yes, Please Give Details (Dosage & Response)
Salt (Freshwater Fish Only)*

YesNo
If Yes, Please Give Details (Dosage & Response)
Malachite Green*

YesNo
If Yes, Please Give Details (Dosage & Response)
Antibiotics (e.g. Oxytet, Nitrofurazone, Sulphonamides)*

YesNo
If Yes, Please Give Details (Dosage & Response)
Antiparasitic Drugs (e.g. Fenbendazolem Metronidazole, Praziquantel)*

YesNo
If Yes, Please Give Details (Dosage & Response)
What Water Conditioners Have Been Used In The Last 3 Months?*
AQUARIUM ENVIRONMENT
What Type Of Aquarium Is Used?*

Cold FreshwaterCold MarineTropical FreshwaterTropical Marine
What Is The Salinity?*
What Is The Water Temperature?*
What Water Source Is Used?*

Real SeawaterArtificial SeawaterFresh Tap WaterOther
If Other, Explain
What Type Of Water Change System Do You Operate?*

Closed (No Water Change)Semi-Open (Partial Water Change)Open (Tidal Or Periodic Water Change)
How Often Do You Perform Water Changes?*
What Percentage Of The Water Is Changed?*
Do You Use Biological Filtration?*

YesNo
If Yes, Please Give Details:
Do You Use Mechanical Filtration? (e.g. Sponge Filters)*

YesNo
If Yes, Please Give Details:
Do You Use Chemical Filtration? (e.g. Activated Charcoal, Chlorine))*

YesNo
If Yes, Please Give Details:
Do You Use Ozone?*

YesNo
If Yes, Please Give Details:
Do You Use Protein Skimmers?*

YesNo
If Yes, Please Give Details:
Do You Oxygenate The Water?*

YesNo
If Yes, Please Give Details:
What Decor & Furnishings Are Present? 9Including Bottom Substrate)*
Are Plants Present?*

YesNo
If Yes, Please Give Details:
Do You Quarantine Plants?*

YesNo
If Yes, Please Give Details:
When Were Plants Last Added To Your Aquarium Or Pond?*
Is Additional Lighting Provided?*

YesNo
If Yes, What Type Of Light Is Used?

Fluorescent Strip LightMetal Halide Lamp
Lightbulb Number, Make, Model, & Manufacturer, If Known:
How Many Hours Of Light Are Provided Each Day?
When Was The Light Last Replaced?
Is There Ever Access To Direct Sunlight? (Not Through Glass Or Plastic)*

YesNo
If Yes, How Many Hours Per Day Or Per Week?
Do You Measure Ammonia?*

YesNo
If Yes, Please Provide Recent Results:
Do You Measure Nitrite?*

YesNo
If Yes, Please Provide Recent Results:
Do You Measure Nitrate?*

YesNo
If Yes, Please Provide Recent Results:
Do You Measure pH?*

YesNo
If Yes, Please Provide Recent Results:
Do You Measure Water Oxygen?*

YesNo
If Yes, Please Provide Recent Results:
How Often Is The Aquarium Cleaned?*
What Cleaning/Disinfectant Agents Are Used?*
DIET & NUTRITION
What Type Of Food Is Fed?*
Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):
Flakes: Yes/No* . Brand: blanks*. Amount: blank*.
Pellets: Yes/No* . Brand: blanks*. Amount: blank*.
Plant/Produce: Yes/No* . Type: blanks*. Amount: blank*.
Invertebrates: Yes/No* . Type: blanks*. Amount: blank*.
Vertebrates: Yes/No* . Type: blanks*. Amount: blank*.
Other Foods:
Do You Use Any Nutritional Supplements?*

YesNo
If Yes, Please Provide Details: (Make/Manufacturer)
If Yes, How Much Is Used & How Often?
Should be Empty:

AQUATIC ANIMAL HISTORY FORM

FISH, INVERTEBRATES & TREATMENTS

REASON FOR PRESENTATION TODAY

Have You Treated With Any Of The Following Products?

AQUARIUM ENVIRONMENT

DIET & NUTRITION