REPTILE HISTORY FORM LinkedInThis field is for validation purposes and should be left unchanged. Date MM slash DD slash YYYY PATIENT INFORMATIONSpeciesGender Male Female Unknown Date of Birth/Hatch MM slash DD slash YYYY Date of Acquired MM slash DD slash YYYY How big was the reptile when you first acquired it?Source (pet store, breeder, previous owner):Breed Captive Breed Wild Caught Number of previous owners (other than breeder,store)ENVIRONMENTWhere is the reptile kept in the house?EnclousureCage: type,size?What material is used to line the bottom of the cage?What types of hiding places are provided?List species of live plants:Is there a soaking/swimming tub?Please describe any other furnishings:How often is the cage cleaned, and what cleaning products are used?Aquatic SpeciesHow often is the water changed?What type of filtration is used?Do you use a dechlorinator or any other type of watertreatment?LightingDoes your reptile receive sunlight? Yes No Estimated hours per week for sunlightDoes the sunlight pass through glass or plastic before reaching the reptile? Yes No Artificial lighting: Incandescent(“screw-in” bulbs) Fluorescent (tube bulbs) Wattages of incandescent bulbsHours / day of incandescent bulbsBrands of flourescent tubesHours / day of brands of flourescent tubesHow often are the fluorescent bulbs changed?TemperatureDo you have a thermometer(s) in the cage? Yes No What is the temperature in the coolest part of the cage?What is the temperature in the warmest part of the cage?What device(s) are used to maintain the temperature? Hot rock Heat pad Warm room Heat light Ceremaic heater Aquarium heater Others Other device(s) are used to maintain the temperature?Is there a thermostat? Yes No Is the temperature decreased at night? Yes No How much temperature decreased at night?HumidityIs the cage misted? Yes No How much cage is misted?Is the humidity measured? Yes No Range of HumidityHow much time does your reptile spend outside of the enclosure?Is your reptile supervised when it is out? Always Sometimes Never Is supplemental heating provided outside the cage? Yes No Type of supplemental heating provided outside the cage?Have you ever noticed your reptile eat any household objects?Is the reptile ever taken outside? Yes No Do you have other pets? Yes No List other animals that are kept in the same cage:Recent acquisitions (new pets within the past 6 months) – species, date,source:List any other pets you have:Are any of your other pets ill? Yes No List recent changes in the environment, if any:DietWhat percent of your reptile’s diet consists of the following (please describe what the animal actually eats, rather than what is offered):Vegetables, fruits %, list types:Insects, mealworms, etc. %, list types:Are they “gut loaded” or dusted before feeding to your reptile? Describe:Rodents, chicks, etc. %, list types & sourceAre Rodents, chicks fed Live Killed Both Pellets, commercial diet or canned food % list types:Any other diet (amount and type):How often do you feed your reptile?Does your reptile eat anything other than its intended diet (e.g. the cat’s food, houseplants)?Please list any supplements used. How are they given and howoften?How is water offered (e.g. dish, misting, drip system)?Please describe any recent change to your pet’s diet.When was the last shed? Was it normal?REPRODUCTIVEDo you plan on breeding this pet in the future? Yes No Possibly Has this reptlie been bred before? Yes No How many clutches/litters has this reptile produced?When was the most recent clutch/litter?How many eggs/babies were laid?Has your reptile ever had difficulty laying? Yes No Describe difficulty in layingWere the offspring healthy Yes No Describe offspring health issueHas your reptile ever been tested or treated for internal or external parasites? Please describe dates and medications used:Previous conditions, problems, or operations (list with date, if know)Your reptile here for: A well pet check-up Is it sick If your reptile is sick, please describe the signs and how long your reptile has been showing these signs:Is your reptile's general activity level Normal Decreased Increased Is your reptile's appetitie Normal Decreased Increased Have you noticed any of the following Select All Weight loss Weight gain Discharge from the eyes or nose Increased breathing rate or effort A change in the droppings Abnormal skin color or shedding Parasites on the skin or in the feces Weakness MISCELLANEOUSPrevious vet namePrevious vet location and contact numberIs your pet currently on any medications? Please list them and their dosageHas your pet been on any medications recently? If yes, please list them and their dosageHave you used any medications from a petstore?Is there anything you want us to done today like nail trim etc?Any questions?
