Reptile/Amphibian Patient History Form

Owner Name

First Last

Phone Number

Date and time of appointment?

Species

Color

Age

How long have you had this pet?

From where did you obtain this pet?

Sex

Determined by

Does this pet have a reproductive history?

(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?

If yes, please give details

Any recently added food or dietary changes?

If yes, please give details

What water supply do you provide?

How often is it changed?

How is water provided?

How often?

Do you use any water supplements?

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?

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?

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?

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?

Please give details

Does your pet have regular exposure to sunlight?

Frequency and length of time

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

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?

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

Please give details

Has your pet been seen by another veterinarian?

Please give details

Have you noticed any change in your pet’s behavior?

Please give details

Have any reptiles in the house become sick or expired in the last year?

Diet

Cage Environment

Reason for presentation today

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Location

Contact Us

Hours

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