Reptile History Form Reptile History Form Your Pet’s Information:Name* Common name or species* Origin* Captive bred Wild caught Unknown Date of Birth or estimated age* Sex* Neuter/Spayed?* No Yes Unknown How long have you had your pet?* From where did you obtain your pet?* Do you have other pets or reptiles in the household?* Yes No Please list number and species* Enclosure DetailsHottest (basking) temperature* Coolest temperature* Are these temperature measured using a thermometer?* Yes No Do you measure humidity in the cage?* Yes No What is the humidity?* What type of cage is used?* Arboreal (tall, climbing) Terrestrial Aquatic What is the cage made of?* Plastic Wooden Metal Glass What is in the cage set up (décor, toys, ventilation, Substrate, etc) ?* Are bathing facilities/bowls provided?* No Yes How often do you clean the cage and what do you clean it with?* What heating equipment is used (ceramic, bulb, water heater, rock, etc)? Can reptile touch or access the heat source?* No Yes Does your reptile have exposure to sunlight (Not through glass or plastic)?* No Yes How often and how long? Does your pet have exposure to UVA and UVB lighting? Yes No Give details on light bulb type and how often do you change bulb* What is your pet’s day and night cycle (hours of sleep)?* What percentage of the time does your pet spend in the cage?* Is your pet supervised when out of the cage?* Yes No Have there been any changes in the environment in the last 3 months?* Yes No If so, please explain: Diet DetailsHow often do you feed your pet?* Please select which foods are eaten:* Vegetables Flowers Fruits Insects Rodents Others Vegetables: Type, Brand and amount* Flowers: Type, Brand and amount* Fruits: Type, Brand and amount* Insects: Type, Brand and amount* Rodents: Type, Brand and amount* Treats/others: Type, Brand and amount* Are the prey fed* Live Freshly killed Frozen/thawed Wild caught N/A Do you use any nutritional supplements in food or water?* Yes No What is it, how much, how often?* Water DetailsWhat water supply do you provide?* City tap water Bottled water Well water How is water provided?* Bowl Dripper system Sprayed How often is water changed?* Reason for Visit todayWhat is the primary reason why you brought your pet in to see a veterinarian today?*Have you noticed any changes in feeding or drinking behavior?* Yes No Please give details* Have you noticed any changes in droppings?* Yes No Please give details* Has your pet had any previous health problems OR reproductive problems?* Yes No Please give details* When was your pet’s last shed?* How often has your pet been shedding?* Have any other pets or person in the household had any illness within the last 30 days?* Yes No Please give details* Has your pet received any medications or treatments in the last 3 months (what was used, dosage, how often and duration):*Please attach a photo of your pet’s enclosure, cage, or aquarium.Max. file size: 8 MB.
