Reptile History FormReptile History FormYour Pet’s Information:Name*Common name or species*Origin* Captive bred Wild caught UnknownDate of Birth or estimated age*Sex*Neuter/Spayed?* No Yes UnknownHow long have you had your pet?*From where did you obtain your pet?*Do you have other pets or reptiles in the household?* Yes NoPlease list number and species*Enclosure DetailsHottest (basking) temperature*Coolest temperature*Are these temperature measured using a thermometer?* Yes NoDo you measure humidity in the cage?* Yes NoWhat is the humidity?*What type of cage is used?* Arboreal (tall, climbing) Terrestrial AquaticWhat 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 YesHow 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 YesDoes your reptile have exposure to sunlight (Not through glass or plastic)?* No YesHow often and how long?Does your pet have exposure to UVA and UVB lighting? Yes NoGive 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 NoHave there been any changes in the environment in the last 3 months?* Yes NoIf so, please explain:Diet DetailsHow often do you feed your pet?*Please select which foods are eaten:* Vegetables Flowers Fruits Insects Rodents OthersVegetables: 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/ADo you use any nutritional supplements in food or water?* Yes NoWhat is it, how much, how often?*Water DetailsWhat water supply do you provide?* City tap water Bottled water Well waterHow is water provided?* Bowl Dripper system SprayedHow 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 NoPlease give details*Have you noticed any changes in droppings?* Yes NoPlease give details*Has your pet had any previous health problems OR reproductive problems?* Yes NoPlease 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 NoPlease 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: 128 MB.Δ
