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 NameLast 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*

MaleFemale
Fixed*

NeuteredSpayedUnknown
Origin*

Captive BredWild CaughtImportUnknown
How Long Have You Had This Animal?*
From Where Did You Obtain This Animal?*
Does This Reptile Have A Reproductive History*

YesNo
Please Give Details:
When Did Your Reptile Last Shed?*
How Often Has Your Reptile Been Shedding?*
Do You Have Other Reptiles Or Pets?*

YesNo
Please Give Details:
Have You Or Your Reptile Had Any Contact With Other Reptiles In The Last 30 Days?*

YesNo
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?*

YesNo
If Yes, Please Give Details (What Was Used, Dosage, How Often, Duration)
Have You Noticed Any Change In Your Reptile's Behavior?*

YesNo
If Yes, Please Give Details
Have Any Other Animals Or Persons In The Household Had Any Illness In There Last 30 Days?*

YesNo
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?*

YesNo
If Yes: What, How Much, & How Often?
Calcium With Vitamin D3, Calcium Without D3, Multivitamin
What Water Supply Do You Provide?*

Tap WaterBottled WaterRain/River Water
How Is The Water Provided?*

BowlDripper SystemSpray
How Often?*
How Often Is The Water Changed?*
Do You Use Water Supplements?*

YesNo
Please Give Details:*
Have You Noticed Any Changes In Feeding Or Drinking Behavior?*

YesNo
Please Give Details:*
Have You Noticed Any Changes In Droppings (Fecal Material, Urine and Urates)?*

YesNo
Please Give Details:*
CAGE ENVIRONMENT
What Type Of Cage Is Used?*

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

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

YesNo
Please Give Details:*
Are Bathing/Spraying Facilities Provided?*

YesNo
Please Give Details:*
Where Is The Cage Located?*

InsideOutside
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?

YesNo
Spotlight/Bulb
How Much Power In Watts? (__W)
Thermostat Control?

YesNo
Heat Mat
Size:
Thermostat Control?

YesNo
Location Of Heat Mat?

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

YesNo
Please Give Details:*
Can The Animal(s) Touch Or Access The Heat Source?*

YesNo
Please Give Details:*
Is There Additional Lighting Provided Inside The Cage?*

YesNo
If Yes, What Type Of Light Is Used?

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

YesNo
Please Give Details:*
Can The Animal(s) Touch Or Access The Light Source?*

YesNo
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?*

YesNo
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?*

YesNo
Does Anyone In The Household Smoke?*

YesNo
Do You Use Any Aerosolized Products?*

YesNo
Have There Been Changes In The Animal's Environment In The Last 3 Months?*

YesNo
Please Give Details:*
IF AQUATIC
Aquarium Heater Wattage
Thermostat Control

YesNo
Filter Type

In TankHang On FilterCanisterOther
Temperature Of Water:
Temperature Measured With Thermometer?

YesNo
How Often Water Quality Checked (Ammonia, Nitrates, Nitrites, pH)
Basking Platform?

YesNo
Water Conditioner?

YesNo
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