Reptile History Form Your Pet’s Information:Name*Common name or species*Origin*Captive bredWild caughtUnknownDate of Birth or estimated age*Sex*Neuter/Spayed?*NoYesUnknownHow long have you had your pet?*From where did you obtain your pet?*Do you have other pets or reptiles in the household?*YesNoPlease list number and species*Enclosure DetailsHottest (basking) temperature*Coolest temperature*Are these temperature measured using a thermometer?*YesNoDo you measure humidity in the cage?*YesNoWhat is the humidity?*What type of cage is used?*Arboreal (tall, climbing)TerrestrialAquaticWhat is the cage made of?*PlasticWoodenMetalGlassWhat is in the cage set up (décor, toys, ventilation, Substrate, etc) ?*Are bathing facilities/bowls provided?*NoYesHow 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?*NoYesDoes your reptile have exposure to sunlight (Not through glass or plastic)?*NoYesHow often and how long?Does your pet have exposure to UVA and UVB lighting?YesNoGive 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?*YesNoHave there been any changes in the environment in the last 3 months?*YesNoIf 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*LiveFreshly killedFrozen/thawedWild caughtN/ADo you use any nutritional supplements in food or water?*YesNoWhat is it, how much, how often?*Water DetailsWhat water supply do you provide?* City tap water Bottled water Well water How is water provided?*BowlDripper systemSprayedHow 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?*YesNoPlease give details*Have you noticed any changes in droppings?*YesNoPlease give details*Has your pet had any previous health problems OR reproductive problems?*YesNoPlease 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?*YesNoPlease 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.
