Reptile History Form – Kensington Bird & Animal Hospital

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Reptile History Form

General Information
Your Name*
First Last
Pet's Name*
Species*
Reptile is a:*
- Pet
- Breeder
Approximate Age*
Sex*
Method of Sexing*
Please Specify Other*
Length of Ownership*
If female, has the reptile ever produced eggs or given birth?*
If yes, when?*
How was the reptile acquired?*
- Store
- Reptile show/expo
- Rescue
- Other
If other, please specify:*
When did the reptile last have a bowel movement?*
Where there any abnormalities? If yes, please describe:*
When did the reptile last shed?*
Description:*
- Complete
- Partial
- Unsure
Housing
Where is the reptile kept?*
Percentage of time kept indoors:*
Percentage of time kept outdoors:*
Percentage of time kept roam free indoors:*
Describe the reptile's enclosure (size, material, items inside)*
Please upload an image or sketch of your enclosure*
What type of bedding is used?*
- Newspaper
- Carpet
- Sand
- Mulch
- Other
Please specify other:*
Is the reptile housed alone?*
- Yes
- No
Please specify:*
What are the heat sources? (Check all that apply)*
- Bulbs
- Heat tape/radiant heat panels
- heat rock
- Ceramic heat emitter
- Under tank heater
- Mercury vapor bulbs
- Other
Please specify other:*
Daytime enclosure temperate:*
Basking enclosure temperate:*
Nighttime enclosure temperate:*
How is heat measured?*
- Digital
- Gauge
- Other
Please specify other:*
What strength UVB bulb is used?*
- 2.0
- 5.0
- 10.0
- None
- Other
Please specify other:*
Distance UVB bulb is from bottom of the cage:*
How many watts is the UVB?*
When was the UVB bulb last changed?*
Humidity percentage?*
How is humidity measured?*
- Digital
- Gauge
- Other
Please specify other:*
How is humidity maintained? (Check all that apply)*
- Misted
- Fogger
- Large water dish
- Other
Frequency of misting?*
Please specify other:*
How often is the reptile soaked?*
Has the reptile's environment changed recently?*
- Yes
- No
Please explain:*
Has the reptile ever hibernated? If so, when?*
Diet
When was the last time the reptile ate?*
Describe what foods are offered:*
Are any vitamins/minerals offered?*
- Yes
- No
Type and frequency given:*
Have there been any changes or new foods?*
- Yes
- No
Please explain:*
How is water offered?*
- Water dish
- Dripper
- Fountain
- Other
Please specify other:*
Reason for Appointment
Is this a wellness exam?*
- Yes
- No
Please describe any signs you noticed that prompted this appointment:*
How long have you noticed this problem?*
Has your reptile been sick previously?*
Has the reptile been seen by another veterinarian?*
- Yes
- No
If yes, please include name and phone number of veterinarian*
Have any test been conducted on the reptile previously?*
- Bloodwork
- Fecal parasite test
- Skin scraping/culture
- X-Rays
- Other
Please specify other:*
Please upload photo of enclosure (optional):

Contact.

977 Farmington Ave
Kensington, CT 06037

Phone: (860) 828-7736

Fax: (860) 829-0594

Hours.

Monday – Friday
8:00am – 5:00pm

Saturday
8:00am – 12:00pm

Sunday
Closed

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About Us
Emergency Care
Clinic Forms
- Forms
- Forms
Services
Pet Health
Contact Us
- Make An Appointment
Wildlife & Disease Outbreaks

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