Reptile History Form

PATIENT INFORMATION

Date

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?

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?

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:

PATIENT INFORMATION

ENVIRONMENT

What are the dimensions of the enclosure?

DIET

REASON FOR VISIT TODAY

Where to Find Us