Forms

Reptile & Amphibian History Form

A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about you can discuss it in more depth with the veterinary staff during your appointment.

Client Information

Animal Details

Name or identification:

Common or scientific species name:

Date of birth:

Age:

Sex: M M Neutered F F Spayed Unknown

Determined by: Probing Endoscopy DNA Visual Unknown

Origin:

How long have you had this animal?

From where did you obtain this animal?

Does your reptile/amphibian have a reproductive history?

Please give details:

When did your animal last shed?

How often has your animal been shedding?

Any trouble shedding?

Do you have any other reptiles/amphibians or other pets?

Please give details:

Have you or your animal had any contact with other reptiles or amphibians in the last 30 days?

Please give details:

When was the last reptile/amphibian added to your collection?

Reason For Presentation Today

What is the primary complaint or what signs you have noticed?

How long have these problems been present?

What health problems has your reptile/amphibian had previously?

Has your animal received any treatment in the last 30 days?

Please give details (what was used, dosage, how often, duration?)

Have you noticed any change in your animal's behavior?

Please give details:

Have any other animals or persons in the household had any illness in the last 30 days?

Cage Environment

What type of cage is used?

Cage size:

Where is the cage located?

Please give details:

What is the cage made of? Plastic/fiber glass Wooden Metal Glass

What décor and furnishings are present? Hide box(es) Humidity box(es) Water bowl Branches

What type of substrate is used? (e.g., coconut byproduct, carpet, gravel, wood shavings, newspaper...)

Does the cage have ventilation (grills or mesh)?

Please give size / details:

Are soaking/bathing facilities provided?

Please give details:

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

What percentage of time does your animal spend inside and outside of its cage?

Is the animal supervised when out of the cage?

What heating equipment is used?
Ceramic/infrared

Spotlight/bulb

Heat mat

Aquarium water heater

Other heaters

Are the heat sources protected/screened from the animals?

Please give details:

Can the animal(s) touch or access the heat source?

Please give details:

How many hours of heat are provided each day and how?

Is additional lighting provided inside the cage?

If yes, what type of light is used?

What is the model and manufacturer?

When was the light last replaced?

Are the lights protected/screened from the animals?

Please give details:

Can the animal(s) touch or access the light source?

Please give details:

How many hours of light are provided each day and how?

Is your animal exposed to full spectrum (UVA and UVB) lighting?

How far away from the animal is it located?

What is the model and manufacturer?

When was the light last replaced?

Is there any material (e.g., screening, mesh, glass) between the bulb and the animal?

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 are the day-time temperatures?

What are the night-time temperatures?

Are these temperatures measured using a thermometer?

Does anyone in the household smoke?

Do you use any aerosolized products?

Have there been changes in the reptile's environment in the last 3 months?

Please give details:

Diet

How often do you feed your animal?

Where do you feed your animal?

Indicate which foods are eaten and in what amounts (by number, weight, or approx.. volume):

Vegetables and/or fruits:

Flowers:

Other plant material:

Pellets:

Insects:

Live or freeze-dried?

Insects, how often fed, type, size and number per feeding:

Are the insects gut-loaded before they are fed to your animal?

Please give details:

Rodents

Rodents, how often fed, type, size and number per feeding:

For large carnivores, do you feed other types of small mammals (e.g., rabbits)?

Do you feed your animal any birds or fish?

Please give details:

Do you feed any wild caught animals to your animal?

Please give details:

Please give details of any other food items fed:

Do you use any nutritional (e.g., calcium, multivitamin) supplements?

If yes what, how much, and how often:

What water supply do you provide?

How is water provided?

Bowl Dripper system Direct misting How often?

How often is the water source changed?

Do you use any water supplements?

Please give details:

Have you noticed any changes in feeding or drinking behavior?

Please give details:

Have you noticed any changes in droppings (fecal material, urine and/or urates)?

Please give details:

Any other comments or information:

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