Reptile History Form

Reptile 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.
Client Name*

First NameLast Name
Animal Details
Reptile Name or Identification*
Common or Scientific Species Name*
Date of Birth

MonthDayYear
Date
Age
Sex
Origin
How long have you had this animal?
Where did you obtain this animal?
Does your 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 any other reptiles or pets?

YesNo
Please explain:
Have you or your reptile had contact with other reptiles in the last 30 days?

YesNo
Please give details:
When was the last reptile added to your collection?

MonthDayYear
Date

Reason for Visit
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? Please provide details below (what was used, dosage, how often, duration), or type 'n/a' if not applicable.
Have you noticed any change in your reptiles behavior?

YesNo
Please provide details:
Have any other animals or persons in the household had any illness in the last 30 days?