Reptile History Form Reptile Form – Digital Version Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Owner Personal InformationName *FirstLastEmail *Patient InformationReptile name or identificationCommon or scientific species nameDate of birthAgeSexMFNeutered/SpayedUnknownOriginCaptive bredWild caught importUnknownHow long have you had this animal?From where did you obtain this animal?Does this animal have a reproductive history?NoYesWhen did your animal last shed?How often has your animal been shedding?Do you have other animals or pets?NoYesHave you or your animal had any contact with other animals in the last 30 days?NoYesWhen was the last animal added to your collection?Reason for VisitWhat is the primary complaint or what signs have you noticed? How long have these problems been present?What health problems has your reptile had previously?as your reptile received any treatment in the last 30 days?YesNoYHave you noticed any change in your reptile's behavior?YesNoHave any other animals or persons in the household had any illness in the last 30 days?Cage EnviormentWhat type of cage is used?Arboreal (tall, climbing)TerrestrialAquaticCage sizeWhat is the cage made of?Plastic/FibreglassWoodenMetalGlassOtherWhat décor and furnishings are present?Is there additional ventilation (grills or mesh)?NoYesAre bathing facilities provided?NoYesHow often is the cage cleanedWhat cleaning/disinfectant agents are usedWhat heating equipment is usedCeramic/infraredSpot light/bulbHeat matAquarium water heaterOther heatersAre the heat sources screened from the animals?NoYesCan the animal(s) touch or access the heat source?NoYesIs additional lighting provided inside the cage?NoYesAre the additional heat sources screened from the animals?NoYesCan the animal(s) touch or access the additional heat source?NoYesHow many hours of light are provided each day?Is there ever access to direct sunlight (not through glass or plastic)?NoYesDo you measure the humidity in the cage?NoYesWhat are the day time temperatures? Hottest area, basking areaWhat are the day time temperatures? Coolest areaWhat are the night time temperatures? Hottest area, basking areaWhat are the night time temperatures? Coolest areaAre these temperatures measured using a thermometer?YesNoDoes anyone in the household smoke?YesNoDo you use any aerosolized products?YesNoHave there been changes in the animal's environment in the last 3 months?YesNoDietHow often do you feed your animal?Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume) Plant materialVegetablesFlowersFruitsInsectsCricketsLocustsMealwormsWaxwormsEarthwormsOthersRodentsMiceRatsBirds or fishDo you feed any wild animals to your animal?NoYesAny other food items fed?NoYesWhat water supply do you provide?Tap waterBottled waterRain/river waterHow is water provided?BowlDripper systemSpray illness you in How often?How often is the water changed?Do you use any water supplements?NoYesHave you noticed any changes in feeding or drinking behavior?NoYesHave you noticed any changes in droppings (fecal material, urine and urates)?NoYesAny other comments or informationUpload Photo(s) Click or drag a file to this area to upload. Submit Now
