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Reptile History Form
It is important to provide an accurate history of your pet to receive the best treatment options available. Please provide answers to the questions below:
PATIENT INFORMATION
Date
Date Format: MM slash DD slash YYYY
Name
*
Species
Breed
Date of Birth/Hatch
Gender
Male
Female
Unknown
Spayed / Neutered:
Yes
No
How do you know the gender of your reptile?
DNA
Surgically
Physical Traits
Probe
Ultrasound
Untitled
Breeder
Pet Store
Friend/Family
Rescue
Found/Caught
Where did you obtain your reptile?
How long have you had your reptile?
What other pets are kept in the house and do they interact?
ENVIRONMENT
What type of enclosure does your reptile live in?
What are the dimensions of the enclosure?
Height
Width
Length
What type of cage furnishings do you have?
Natural branches
Fake branches
Foliage
Real Plants
Stones
Dig Box
Water Bowl
Hide Box
Other
What is on the bottom of the enclosure?
Newspaper
Corn cob
Kitty Litter
Towel
Tile
Paper towel
Wood shavings/chips
Rubber mat
Indoor/outdoor carpet
Dirt
Moss
Bare gravel
Calci-Sand
Play sand
Other:
Other
What is the temperature?
WARM SIDE
COLD SIDE
Are there any changes for overnight?
How do you measure the temperature?
Thermostat
Thermometer
Location in tank
Is it digital?
Yes
No
How do you heat the enclosure?
Light bulbs
Heat cable
Heat tape
Hot rock
Room heater
Under tank heaters
Ceramic heat emitters
Mercury bulbs
Water heater
Other
Other:
What is the humidity of the environment and how do you measure it?
How do you control the humidity?
Humidifier in room
Mister/fogger
Drip set
Spraying
How is water offered?
Dish
Tray
Dropper/mister
Portion of cage
Aquatic
Soaking
How is water filtered?
In-tank filter
Bio-wheel
Canister
None
How often is water changed?
Do you have a UV light, what kind of light is it?
How often do you replace it?
Does your pet get natural sunlight?
Yes
No
If yes, how?
Outdoors
Window
How long?
How long are the lights on/off? Day:
Night
DIET
What do you feed your pets?
How often do you feed your pet?
How often does your pet defecate?
Do you use:
Calcium
Calcium with phosphorus
Calcium with D3
Multi-vitamin
If applicable, how often do you use calcium?
Multi-vitamin?
Are you supplements in the form of dusting or gut-loaded prey; and how long after are they fed?
REASON FOR VISIT TODAY
What is the primary complaint or what signs have you noticed?
How long have these problems been present?
What health problems has your pet had previously?
Has your pet received any treatment in the last 30 days?
Yes
No
If yes, please give details (what was used, dosage, duration, frequency, etc.)
Have you noticed any changes in your pet’s behavior?
Have any other animals in the household had any illness in the last 30 days?
Yes
No
If yes, please describe:
Δ
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