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Reptile/Amphibian Patient History Form
Owner Name
First
Last
Phone Number
Date and time of appointment?
Date Format: MM slash DD slash YYYY
Species
Color
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?
No
Yes
(egg laying, etc.)
Please give details
When was the last reptile/amphibian added to your collection?
Diet
How often do you feed your pet?
Indicate which foods are eaten and specify amounts below
Insects
Pellets or other formulated
Fruits and/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?
No
Yes
If yes, please give details
Any recently added food or dietary changes?
No
Yes
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
Spray
How often?
Do you use any water supplements?
No
Yes
If yes, please give details
Have you noticed any changes in eating or drinking behavior? Please give details
Have you noticed any changes in droppings (fecal material, urine and urates)? Please give details
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?
At what temperature is the enclosure kept?
Daytime
Nighttime
Basking site
Is a thermometer used?
No
Yes
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 décor or furnishings are present?
Hide box
Humidity Box
Vegetation
Toys
Other
Please give details
Are bathing/spraying facilities provided?
No
Yes
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 its cage?
Inside
Outside
Is your pet supervised when out of the cage?
No
Yes
Please give details
Does your pet have regular exposure to sunlight?
No
Yes
Frequency and length of time
Is your pet exposed to full spectrum (UVA and UVB) lighting?
No
Yes
Brand
Date of bulb purchase
Date Format: MM slash DD slash YYYY
Distance from top of enclosure, perches, etc?
Have there been any changes in the pet’s environment in the last 3 months?
No
Yes
Please give 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 pet had previously?
Has your pet received any treatment in the last 30 days
No
Yes
Please give details
Has your pet been seen by another veterinarian?
No
Yes
Please give details
Have you noticed any change in your pet’s behavior?
No
Yes
Please give details
Have any reptiles in the house become sick or expired in the last year?
Home
New Clients
What to Expect
Take A Tour
Make an Appointment
About
Our Hospital
Team
Locations & Hours
Testimonials
FAQs
Payment Info
Services
Additional Services
Alternative and Complementary Therapy
Anesthesia and Patient Monitoring
Breeding Services
Exotic Pet Medicine and Surgery
Health Screening Tests
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Pet Health
Illustrated Articles
How-To Videos
Pet Health Checker
News
FAQs
Links
MyPetED
American Veterinary Medical Association
American Animal Hospital Association
Book Appointment
Client Forms
Curbside Form
New Client Information Form
New Pet Information Form
Reptile/Amphibian Patient History Form
Photo Release Form
Exotic Companion Mammal Patient History Form
Owner Questionnaire
Pet Portal
Online Store