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Date/Time of Appointment
Your Name
Phone Number
Email
Pet's Name
Species
Color/Markings
Birthday/Approximate Age
How long have you had this pet?
From where did you obtain this pet?
Sex
Male
Female
Unknown
Determined By
Probing
Endoscopy
Visually Dimorphic
Other
Does this pet have a reproductive history?
Yes
No
When was the last reptile/amphibian added to your collection?
Diet
Diet
How often do you feed your pet?
Indicate which foods are eaten and specify amounts below.
Insects
Pellets or other formulated
Fruits or vegetables
Meat
Treats
Other
Type of insects/amount
Are insects gut-loaded (fed)? If yes, please give details.
Brand and amount of pellets
Type and amount of fruits and/or vegetables
Type and amount of meat. Live or frozen/thawed?
Brand and amount of treats
If other, please specify
Do you use any nutritional supplements?
Yes
No
If yes, please give details.
Any recently added food or dietary changes?
Yes
No
If yes, please give details.
What water supply do you provide?
Tap
Well
Bottled
Other
How often is it changed?
How is water provided?
Bowl
Dripper System
Tray
How often?
Do you use any water supplements?
Yes
No
If yes, please give details.
Any changes in eating or drinking behavior? Please give details.
Any changes in droppings (fecal material, urine and urates)? Please give details.
Cage Environment
Cage Environment
Where is the cage located?
Inside
Outside
Please give details.
What is the cage made of?
Cage Dimensions
What kind of bedding or substrate is used?
Daytime Temperature
Nighttime Temperature
Basking Site Temperature
Is a thermostat used?
Yes
No
Number and location in relation to heating source
What type of heat source is used?
Heat lamp
Undertank heater
Ceramic heating element (rock)
What is the humidity level inside the enclosure?
How is it measured?
What decor or furnishings are present?
Hide box
Humidity box
Vegetation
Toys
Other
Are bathing or spraying facilities provided?
Yes
No
Please give details.
How often is the cage cleaned?
What kind of soap/disinfectant do you use?
What percentage of time does your pet spend inside and outside of it's cage?
Is your pet supervised when out of the cage?
Yes
No
Please give details.
Does your pet have regular exposure to sunlight?
Yes
No
Is your pet exposed to full spectrum (UVA and UVB) lighting?
Yes
No
Brand
Date of Bulb Purchase
Distance from top of enclosure, perches, etc...?
Have there been any changes in the pet's environment in the last 3 months?
Yes
No
Please give details.
Reason For Presentation Today
Reason For Presentation Today
What is the primary complaint or what signs have you noticed?
How long have these problems been present?
Previous Veterinarian/Vet Clinic
Any Other Medical Conditions You Wish to Explain
What health problems has your pet had recently?
Have any reptiles in the house become sick or expired in the last year?
Yes
No
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