Reptile & Amphibian History Form

Reptile name or identification of patient

Name of owner

First Last

Common or scientific name:

Date of Birth and/or Approximate Age

Sex

Origin

Captive Bred
Wild Caught Import
Unknown

How long have you had this animal? From where did you obtain this animal?

Does your reptile have a reproductive history? please give details

When did your reptile last shed? How often has your reptile been shedding?

Do you have any other reptiles or pets? If yes please provide details

When was the last reptile added to your home?

Have you or your reptile had any contact with other reptiles in the last 30 days? If yes please provide details

Reason for presentation today

What is the primary complaint or what signs have you noticed? How long have these problems been present?

What health problems has your reptile/amphibian had previously?

Has your reptile/amphibian received any treatment in the last 30 days? If yes, please give details (what was used, dosage, how often, duration?)

Have you noticed any change in your reptile’s behavior? If yes, please give details

Have any other animals or persons in the household had any illness in the last 30 days? If yes, please give details

Cage Environment

Please describe the cage that is being used (Arboreal (tall, climbing) Terrestrial Aquatic Cage sizeWhat is the cage made of? Plastic/fiberglass Wooden Metal Glass Other)

What substrate or bedding is used?

What decor and furnishings are present?

Is there additional ventilation (grills or mesh)? please give size/details:

How often do you bathe your reptile? Describe bathing routine:

What heating/lighting equipment is used? (Non-heating UVA/UVB bulb/Combo bulb Heat + UVA/UVB bulb/Ceramic/ Spot light or incandescent bulb/heat mat/ Aquarium water heater/thermostat control/ other. Please provide as much detail such as brand and model, power, date of most recent change, where it's placed. Etc)

Are the heat/light sources screened from the animals? please give details:

Can the animal(s) touch or access the heat/light source? please give details:

Is additional lighting provided inside the cage? If yes, describe:

How many hours of light are provided each day?

Is there ever access to direct sunlight (not through glass or plastic)? If yes, how many hours per day or per week?

Do you measure the humidity in the cage? If yes, what is the humidity level? What brand/type and location is the hygrometer?

What are the daytime temperatures? Hottest / Basking area? Coolest area?

What are the nighttime temperatures? Hottest / Basking area? Coolest area?

Are these temperatures measured using a thermometer?

Yes
No

What brand/type and location is the thermometer?

Have there been changes in the reptile’s environment in the last 3 months? If yes, please give details:

Does anyone in the household smoke?

Yes
No

Do you use any aerosolized products?

Yes
No

Diet

How often do you feed your animal?

Indicate which foods are eaten and in what amounts (by number, weight, or approximate volume): (Plant material: Vegetables, Flowers, Fruits; Frozen, thawed or other) (Insects: Crickets , Locusts , Mealworms , Waxworms , Earthworms , other:) (Rodents: Mice, Rats, Birds or Fish; Freshly Killed, Frozen/thawed, Live prey)

Do you feed any wild animals to your animal? please give details:

Any other food items fed? please give details:

Do you use any nutritional supplements? If yes, what, how much and how often:

What water supply do you provide? (tap water, bottled water, rain/river water) How is it provided (Bowl, Bottle, Spray) How Often? How often is the water changed?

Do you use any water supplements? If yes, what, how much and how often:

Have you noticed any changes in feeding or drinking behavior? Please give details:

Have you noticed any changes in droppings (fecal material, urine and urates)? Please give details:

Any other comments or information:

Middle Creek Veterinary Hospital has a Facebook page and website that we use to educate clients and share interesting pet stories. May we have permission to use photos of your pet, their story and details of his/her medical history to help educate other clients in this way?

Yes
No

**Client’s names will never be shared. If, at any time, you wish to have your pet’s photo or story removed, please alert one of our doctors.

Monday	9:00am – 5:00pm
Tuesday	10:00am – 7:00pm
Wednesday	9:00am – 5:00pm
Thursday	10:00am – 7:00pm
Friday	9:00am – 5:00pm
Saturday	By Appointment Only
Sunday	Closed

Reason for presentation today

Cage Environment

Diet

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