Reptile/Amphibian Patient History Form – White Rock Veterinary Hospital in Pflugerville, Texas

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512-670-5400

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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
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
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?
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?

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Location

2509 Pecan St. W
Pflugerville, Texas, 78660

Contact Us

Phone: (512) 670-5400
Email: info@whiterockvet.com

Hours

Mon – Fri 7am – 6pm
Sat 8am – 12pm
Sun Closed

Emergencies

Small mammals, cats & dogs:

Emergency Animal Hospital of NW Austin

Phone: 512-331-6121

For cats & dogs:

Emergency Pet Care of Round Rock

Phone: 512-961-5200

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