Reptile Medical History Form
Patient/Owner Information
Patient Name:
*
First Name
Last Name
Date:
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-
Month
-
Day
Year
Date
Owner Name:
*
Presenting complaint:
What is going on?
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When did it start?
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Have you noticed the following symptoms?
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Behavior Change
Lethargy/Decreased Activity
Change in Appetite
Change in Urate
Increasing Breathing Rate/Effort
Retained Spectacles
Tremors
Skin/Fecal Parasites
Vomiting/Regurgitation
Change in Stools
Nasal or Ocular Discharge
Weight Change
Retained Shed/Difficulty Shedding
Weakness
Seizures
None
Other
Have there been any pets in contact with this one that have died within the last month?
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Yes
No
If yes, please explain
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Has this pet been sick at any other time during the last 12 month?
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Yes
No
Please explain and by whom was this pet seen?
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Has this pet been given any medications or supplements in the past 7 days?
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Yes
No
Please describe (type, frequency)
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Does this pet have any previous or chronic medical conditions?
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Yes
No
Please describe
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Does this pet take any medications regularly?
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Yes
No
If so, list medications and dosing schedule
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Has your pet ever been treated for internal or external parasites?
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Yes
No
Please list the medications used
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Patient Information
Reptile Name or Identification
*
Common or Scientific Species Name
*
Is your pet being seen for vomiting and/or diarrhea?
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Yes
No
Origin
*
Captive bred
Pet store
Wild caught
Show
Breeder
Found
Unknown
How long have you owned this pet?
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Where did you obtain this pet?
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Was this pet sexed?
Blood test (DNA)
Visual
Surgical
No
Does you reptile have any reproductive history?
Yes
No
Please give details
*
When did your pet last shed?
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How often has your reptile been shedding?
*
Was the shed one piece, patchy, or incomplete?
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Is your pet housed indoors, outdoors, or both?
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Is your pet housed with another pet?
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Yes
No
How many other animals are housed with your pet?
Are there any other pets in the house?
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Yes
No
If so, what kind?
Please list species, age and sex of each pet
Have you had contact with other reptiles in the last 30 days?
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Yes
No
Please give details
Cage/Enclosure Description
Enclosure Type (Wood With Glass, Glass Tank, Plastic, Mesh/Wire, Yard, Pond, Other)
Dimensions
Cage Lining/Substrate
How often is your pet’s enclosure cleaned and with what products?
Types of Plants or Decor
Is a soaking/swimming tub provided?
For aquatic species, how often is the water changed?
What percent of the water is changed?
Lighting
Please select the type of artificial lighting used for your reptile:
UVA/UVB
Incandescent/screw in bulb
Fluorescent /tube bulb
Brand
Hours on per day
Wattage
How often is it changed
Does your reptile receive sunlight?
Yes
No
Please estimate how many hours per day
Does the sunlight pass through glass or plastic before reaching the pet?
Yes
No
Artificial lighting: UVB lighting?
Incandescent/Screw-In Bulbs and Wattages
Fluorescent/Tube Bulbs and Wattages
Brand
Hours Per Day
How often are the bulbs changed?
Temperature
How is the temperature monitored? (Thermometer in The Cage, Infrared Laser Thermometer/Temperature Gun)
Day Temperature in The Warmest Part of The Cage
Coolest Part
Night Temperature in The Warmest Part of The Cage
Coolest Part
What devices are used for heating? (Heat Rock, Heat Pad, Heat Light, Ceramic Heater, Aquarium Heater, Other)
Is there a thermostat?
Humidity
Is the cage misted?
Yes
No
How often and is it automatic?
Is the humidity measured?
Yes
No
If so, what is the range?
Do you soak your reptile out of the cage?
Yes
No
If so, where and how often?
How much time does your reptile spend outside of the enclosure?
Is your pet supervised when out?
Always
Sometimes
No
Does your reptile go outdoors?
Does your pet have a humid hide/box?
Diet
What Percentage of Diet Consists of The Following (Please List What The Animal Actually Eats) Veggies% _______Fruit% _______ Insects%
(Please List Which Ones)
Are the insects gut loaded and/or dusted before feeding?
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Yes
No
Please describe
Does your reptile eat live or frozen animals? (Rodents, Chicks, Etc)
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Yes
No
Please list type and souce
Does your reptile pellets or a commercial diet?
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Yes
No
Please list type, brand, and amount fed
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Does your pet graze in the yard?
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Yes
No
Please describe
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Do you give supplements? (Vitamin C, Calcium)
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Yes
No
If so, what kind and how frequently?
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How is water offered?
Bowl
Drip System
Misting System
Other
How often are food dishes washed?
What type of soap/disinfectant is used?
Reproductive
Is this animal used for breeding or do they have a breeding history?
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Yes
No
How many clutches/litters has this reptile produced?
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How many live offspring?
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When was the most recent clutch/litter?
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How many eggs/babies?
*
Has your reptile ever had difficulty laying?
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Yes
No
If So, Describe
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