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Animal Medical Professionals
Vet Clinic Ooltewah & Chattanooga
423-238-5870
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423-238-5870
423-238-5870
Home
About Us
Our Doctors
Testimonials
FAQ
Join Our Team
Services
All Services
Diagnostic Laboratory
Pet Surgery
Endoscopy & Ultrasound
Pet Medical Boarding Services
Angel Fund
Online Pharmacy
Forms
Gallery
Blog
Contact
Reptile History Form
You are here:
Home
Reptile History Form
OWNER PERSONAL INFORMATION
First Name
*
:
Last Name:
Email
*
:
Patient Information
Reptile name or identification:
Common or scientific species name:
Date of birth:
Age:
Sex:
M
F
Neutered/Spayed
Unknown
Origin:
Captive bred
Wild caught import
Unknown
How long have you had this animal?:
From where did you obtain this animal?:
Does this animal have a reproductive history?:
N
Y
When did your animal last shed?:
How often has your animal been shedding?:
Do you have other animals or pets?:
N
Y
Have you or your animal had any contact with other animals in the last 30 days?:
N
Y
When was the last animal added to your collection?:
Reason for Visit
What 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?:
Has your reptile received any treatment in the last 30 days?:
N
Y
Have you noticed any change in your reptile's behavior?:
N
Y
Have any other animals or persons in the household had any illness in the last 30 days?:
Cage Enviorment
What type of cage is used?:
Arboreal (tall, climbing)
Terrestrial
Aquatic
What is the cage made of?:
Plastic/Fibreglass
Wooden
Metal
Glass
Other
What décor and furnishings are present?:
Is there additional ventilation (grills or mesh)?:
N
Y
Are bathing facilities provided?:
N
Y
How often is the cage cleaned:
What cleaning/disinfectant agents are used:
What heating equipment is used:
Ceramic/infrared
Thermostat control:
N
Y
Spot light/bulb
Thermostat control:
N
Y
Heat mat
Heat mat position:
Under cage
Inside cage
Thermostat control:
N
Y
Aquarium water heater
Thermostat control:
N
Y
Other heaters
Are the heat sources screened from the animals?:
N
Y
Can the animal(s) touch or access the heat source?:
N
Y
Is additional lighting provided inside the cage?:
N
Y
What type of light is used?:
Light bulb
Fluorescent strip light
Are the additional heat sources screened from the animals?:
N
Y
Can the animal(s) touch or access the additional heat source?:
N
Y
How many hours of light are provided each day?:
Is there ever access to direct sunlight (not through glass or plastic)?:
N
Y
Do you measure the humidity in the cage?:
N
Y
What are the day time temperatures?:
Hottest area, basking area:
Coolest area:
What are the night time temperatures?:
Hottest area, basking area:
Coolest area:
Are these temperatures measured using a thermometer?:
N
Y
Does anyone in the household smoke?:
N
Y
Do you use any aerosolized products?:
N
Y
Have there been changes in the animal's environment in the last 3 months?:
N
Y
Diet
How often do you feed your animal?:
Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):
Plant material:
Vegetables
Type and amount per feed:
Vegetables conditions:
Frozen/thawed
Fresh
Other
Flowers
Type and amount per feed:
Flowers-conditions:
Frozen/thawed
Fresh
Other
Fruits
Type and amount per feed:
fruits-conditions:
Frozen/thawed
Fresh
Other
Insects:
Crickets
Locusts
Mealworms
Waxworms
Earthworms
Others
Rodents:
Mice
Conditions:
Freshly killed
Frozen/thawed
Live preys
Rats
Conditions:
Freshly killed
Frozen/thawed
Live preys
Birds or fish
Conditions:
Freshly killed
Frozen/thawed
Live preys
Do you feed any wild animals to your animal?:
N
Y
Any other food items fed?:
N
Y
What water supply do you provide?:
Tap water
Bottled water
Rain/river water
How is water provided?:
Bowl
Dripper system
Spray
How often is the water changed?:
Do you use any water supplements?:
N
Y
Have you noticed any changes in feeding or drinking behavior?:
N
Y
Have you noticed any changes in droppings (fecal material, urine and urates)?:
N
Y
Any other comments or information:
Upload Photo(s)
Please submit habitat photos below:
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