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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
*
Male
Female
Unknown
Method of Sexing
*
Visual
Probe
Other
Please Specify Other
*
Length of Ownership
*
If female, has the reptile ever produced eggs or given birth?
*
No
Yes
Unknown
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):
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