Reptile History Form

Date

First Name

Last Name

Pet's Name

Patient Information

A detailed history is essential to provide the appropriate veterinary care for your reptile. Please complete this form as accurately as possible. If there is anything you are unsure about, you can discuss it in more depth with the veterinarian during your appointment.

Common or Scientific Species Name:

Gender

MaleFemaleUnknown

Date of birth/hatch:

How big was the reptile when you first acquired it?

Source (pet store, breeder, previous owner):

Choose:

Wild caughtCaptive bred

Number of previous owners (other than breeder, store):

What states and countries has your reptile lived in?

When was the last shed? Was it normal?

Previous conditions, problems, or operations (List date if known):

Has your reptile ever been tested or treated for internal or external parasites?

YesNo

If yes, please describe dates and medications used:

Environment

Where is this reptile kept in the house?

Enclosure (cage type, size):

What is on 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?

Do you have any other pets?

YesNo

List other animals that are kept in the same cage:

Recent acquisitions (new pets within the past 6 months) – provide species, date, and source:

List any other pets you have:

Are any of your other pets ill?

YesNo

Aquatic Species

How often is the water changed?

What type of filtration is used?

Do you use a dechlorinator or any other type of water treatment?

List recent changes in the environment (if any):

Diet

What percent of your reptile’s diet consists of the following (please describe what the reptile actually eats, rather than what is offered):

Vegetable percentage and types:

Fruit percentage and types:

Insects, mealworms, etc. percentage and types:

Are they “gut loaded” or dusted before feeding to your reptile? Describe:

Rodents, chicks, etc. percentage, types and sources:

Are they fed live, killed or frozen?

Pellets, commercial diet or canned food percentage and types:

Other? Please describe:

How often do you feed your reptile?

Please list any supplements used. How are they given and how often?

Does your reptile eat anything other than its intended diet (i.e. the cat’s food, houseplants)?

How is water offered (i.e. dish, misting, drip system)?

Please list any recent additions/changes in the diet:

Reproductive

Do you plan on breeding this reptile?

YesNoMaybe

How many clutches/litters has this reptile produced?

Were they healthy?

YesNo

When was the most recent clutch/litter?

How many eggs/babies were laid?

Were they normal?

YesNo

If no, were they:

MisshapenThin shelled

Were the offspring healthy

YesNo

If no, please describe:

Has your reptile ever had difficulty laying?

YesNo

Describe:

Lighting

Does your reptile receive sunlight?

Estimated hours per week:

Does the sunlight pass through glass or plastic before reaching the reptile?

YesNo

Incandescent (“screw-in” bulbs): Watts & Hours per day

Fluorescent (tube bulbs): Brand(s)?

Hours per day?

How often are the fluorescent bulbs changed?

Temperature

Do you have a thermometer(s) in the cage?

YesNo

What is the temperature in the warmest part of the cage?

In the coolest part?

Is there a thermostat?

YesNo

Is the temperature decreased at night?

YesNo

If yes, by how much?

Humidity

Is the cage misted?

YesNo

Is the humidity measured

YesNo

Range:

How much time does your reptile spend outside of the enclosure?

Is your reptile supervised when it is out?

AlwaysSometimesNever

Is supplemental heating provided outside the cage?

YesNo

Type:

Have you ever noticed your reptile eat any household objects?

Is the reptile ever taken outside?

YesNo

Does your reptile hibernate?

YesNoNon-hibernating Species

Please describe the duration, temperature, and monitoring that you provide during hibernation:

Today’s Visit

What is your reptile here for today?

Wellness ExamSick

If your reptile is sick, please describe the signs and how long your reptile has been showing these signs:

Is your reptile’s activity level:

NormalIncreasedDecreased

Is your reptile’s appetite:

NormalIncreasedDecreased

Have you used any medications from the pet store?

YesNo

If yes, please explain:

Has your reptile been seen by another veterinarian for any of the current problems?

YesNo

If yes, when?

Please list the tests performed and medications given:

Are there any other questions or concerns?