Date
/
Month
/
Day
Year
Date
Admitting Clinician
Appt. Time
Species
Age
Sex
Pet
Breeder
Background Information
Length of time owned
Where acquired from:
Breeder
Pet Store
Other
Wild-caught or Captive Bred?
Deparasitized? Yes/No
If yes, with what?
How often is the animal handled?
Daily
Occasionally
Never
Have you ever taken your animal outside:
Yes
No
If yes, for how long?
When was last shed?
Any trouble shedding?
Yes
No
If yes, specify
Fecal consistency?
Type of enclosure
Size of enclosure
Where is cage located?
Cage furniture
Cage substrate?
Type of Disinfectant used to clean cage:
Frequency of cage cleaning?
Light cycle
Type of lighting
Heat source
Humidity level
Temperature within cage: Minimum
Maximum
Basking area
Type of Food offered
Amount fed/frequency
When last fed
Water Source
Any other pets?
Yes
No
If yes, please specify
Any other reptiles?
Yes
No
If yes, specify
Reptiles are housed together or singly?
If not housed together, where are the other reptiles located?
Any new additions to the reptile population?
Yes
No
If yes, specify
Past Medical History/Problems
Current Presenting Problem
Duration of complaint
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