• 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.
  • Format: (000) 000-0000.

  • ANIMAL DETAILS

  • Sex*
  • Fixed*
  • Origin*
  • Does This Reptile Have A Reproductive History*
  • Do You Have Other Reptiles Or Pets?*
  • Have You Or Your Reptile Had Any Contact With Other Reptiles In The Last 30 Days?*

  • REASON FOR PRESENTATION TODAY

  • Has Your Reptile Received Any Treatment In The Last 30 Days?*
  • Have You Noticed Any Change In Your Reptile's Behavior?*
  • Have Any Other Animals Or Persons In The Household Had Any Illness In There Last 30 Days?*

  • DIET

  • Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):

  • Seed Mixtures: * . Brand: *. Amount: *.

  • Pellets: * . Brand: *. Amount: *.

  • Fruits and/or Vegetable: * . Type: *. Amount: *.

  • Flowers: * . Type: *. Amount: *.

  • Crickets: * . Amount: *.

  • Dubia Roaches: * . Amount: *.

  • Hornworms: * . Amount: *.

  • Mealworms: * . Amount: *.

  • Waxworms: * . Amount: *.

  • Rodent Types (Frozen/Thawed, Freshly Killed, Live Prey, Other)

  • Mice: * . Type: *. Amount: *.

  • Rats: * . Type: *. Amount: *.

  • Birds: * . Type: *. Amount: *.

  • Fish: * . Type: *. Amount: *.

  • Do You Use Any Nutritional Supplements?*
  • What Water Supply Do You Provide?*
  • How Is The Water Provided?*
  • Do You Use Water Supplements?*
  • Have You Noticed Any Changes In Feeding Or Drinking Behavior?*
  • Have You Noticed Any Changes In Droppings (Fecal Material, Urine and Urates)?*

  • CAGE ENVIRONMENT

  • What Type Of Cage Is Used?*
  • What Is The Cage Made Of?*
  • Is There Additional Ventilation? (Grills Or Mesh)*
  • Are Bathing/Spraying Facilities Provided?*
  • Where Is The Cage Located?*

  • What Heating Equipment Is Used?

    Ceramic/Infrared
  • Thermostat Control?

  • Spotlight/Bulb
  • Thermostat Control?

  • Heat Mat
  • Thermostat Control?
  • Location Of Heat Mat?
  • Are The Heat Sources Screened From The Animal(s)?*
  • Can The Animal(s) Touch Or Access The Heat Source?*
  • Is There Additional Lighting Provided Inside The Cage?*
  • If Yes, What Type Of Light Is Used?
  • Are The Lights Screened From The Animal(s)?*
  • Can The Animal(s) Touch Or Access The Light Source?*
  • Do You Measure The Humidity In The Cage?*

  • What Are The Daytime Temperatures? Hottest Area: * . Basking Area: *. Coolest Area: *.

  • What Are The Nighttime Temperatures? Hottest Area: * . Basking Area: *. Coolest Area: *.

  • Is The Animal Supervised When Out Of The Cage?*
  • Does Anyone In The Household Smoke?*
  • Do You Use Any Aerosolized Products?*
  • Have There Been Changes In The Animal's Environment In The Last 3 Months?*

  • IF AQUATIC

  • Thermostat Control
  • Filter Type
  • Temperature Measured With Thermometer?
  • Basking Platform?
  • Water Conditioner?
  • Should be Empty: