Reptile History Form

Please provide the information below as completely as possible. All information is strictly confidential. All fields with an asterisk (*) are required.

Patient Information

Owner's Name*
Pet's Name*
Species*
Age*
Sex*
Male
Female
Unknown
How was reptile sexed?*
Blood Test (DNA)
Surgically
Visually
Probe
Not Sexed
Color/Markings*
Specific Identification
Tattoo
Microchip
Other
Describe ID location and Details (if applicable)

Reason for Today's Visit

What signs prompted today's visit?*
How long have you noticed the problem?*
How has the problem changed?*
Worse
Better
Same
Has anything seemed to make the problem worse or better?
Does the problem tend to happen at a certain time of day or time of year?
On a scale of 1 to 10, with 1 being normal and 10 being death, how would you rate your pet's problem?*
Have you noticed any of the following signs? (check all that apply)
Behavior change
Lethargy / change in exercise
Nose or eye discharge
Sneezing
Increased breathing rate / effort
Vomiting / regurgitation
Change in stool quality
Change in urine / urate quality / color
Change in urine volume
Lameness / weakness
Change in thirst
Change in appetite
Change in weight
Scratching
Skin abnormalities
Skin lumps (masses)
If your reptile has been sick before, please describe.
If your reptile has been seen by another veterinarian, who was that vet?
Please describe any medications your reptile is currently taking.
Have you tried any over-the-counter remedies or supplements?
Please describe any laboratory tests that have been performed on your reptile previously.
Has any member of your household (human or animal) had an illness in the past month?*
Yes
No
Are you aware that any reptile may carry Salmonella bacteria?*
Yes
No

General History

How did you acquire this reptile?*
Source:*
Private Breeder (describe)
Pet Store (describe)
Wild Caught (imported)
Unknown
Please provide any other details on the source.
Approximate date when acquired.*
Approximate age or size when acquired.*
Reptile is a:*
Pet
Breeder
Other
If other, please describe
Has any reproductive behavior been noted?*
Yes
No
If so, please describe.
Please describe any past reproductive issues. Has your bird been "spayed" (undergone a salpingohysterectomy)?
When was the last shed?*
Was that shed normal?*
Yes
No
Do you have any other reptiles or other pets?*
Yes
No
If yes, please list other pets and whether they have contact with this reptile.
Has there been any contact between humans or reptiles in your household with any other reptiles in the last 3 months?*
Yes
No
How does your reptile get excercise?*

Housing

Where is this reptile kept? (select all that apply)*
Indoors
Outdoors
In a cage
Free ranging
Is this reptile housed alone?*
Yes
No
If no, please describe cage mates.
Describe your reptile's enclosure (size, materials, ventilation).*
What substrate and other objects are in the cage? (eg. astroturf, sand, gravel)*
If your reptile is housed in an aquatic environment, please describe any filtration system in place and how often it is cleaned / changed.
Please describe any heat source, including brand and wattage if known.*
Do you have a thermostatic controller for your heat source?*
Yes
No
Basking site temperature (°F):*
Daytime high temperature(°F):*
Daytime low temperature (°F):*
Nighttime high temperature (°F):*
Nighttime low temperature (°F):*
How is the temperature measured (types of thermometers, locations)?*
How close can your reptile get to the heat source?*
Describe any humidity sources.*
Describe humidity level and how it is measured.*
Describe how often your reptile is soaked in water, including how long.*
Describe all light sources (both natural and artificial) and hours used.*
If a UV bulb or full spectrum bulb is in use, please describe type, age of bulb, and hours of use. Also include how often the bulb is changed and distance from your reptile.*
Is there any material (screen, glass ... ) between your UV light and your reptile?*
Yes
No
Does your reptile receive access to direct sunlight (not through glass or plastic)?*
Yes
No
How often is the cage cleaned?*
Describe method of cleaning.*
How often are food and water dishes cleaned?*
Describe method of cleaning.*
Does your reptile hibernate?*
Yes
No
If yes, describe location, temperature range, and duration.
Has your reptile's environment changed recently?*
Yes
No
If yes, please describe.

Diet

How often is food offered to your reptile?*
Where is food offered (enclosure, hand fed, separate enclosure, etc.)?*
If vegetables are given, what types and are they frozen, fresh, dehydrated, or in some other form?
If proteins are offered, list types (insects, fish, cheese, meat) and status (live, frozen, dehydrated).
If insects are gut loaded, describe what they are loaded with and duration of loading prior to being fed to your reptile.
If pellets or commercial diet is given, please give the brand and type.
Please describe any treats that are provided.
What is the predominate diet that your reptile actually eats (for example pellets with some fish or mostly insects that are not gut loaded)?*
Are any vitamin or mineral supplements offered to your reptile?*
Yes
No
if yes, please describe brand, type, and how often.
If there have been any recent diet changes or new foods, please describe them.
How is water provided?*
Bowl
Sipper bottle
Aquatic environment
Other
Which water source is used?*
Tap water
Bottled water
Well water
Rain water
How often is the water changed?*
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