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Home » Client & Patient Forms » Reptile History Form

Reptile History Form

Owner's first and last name(Required)

First

Last

Pet's Name(Required)

First

Common/Species Name(Required)

First

Please enter your pets age / Date of Birth(Required)

What is your pets origin?(Required)

Captive Bred

Wild Caught Import

Unknown

Please select your pets sex:(Required)

Male

Female

Unknown

How was your pets gender determined?(Required)

How long have you had this pet?(Required)

Does your reptile have a reproductive history?

Yes

If answered yes, please provide details:

When did your reptile last shed?(Required)

Do you have any other reptiles or pets?(Required)

Yes

If answered yes, please provide details:

Have you or your pet have contact with any other reptiles in the last 30 days?(Required)

Yes

If answered yes, please provide details:

When was the last reptile added to your collection?

What is your primary concern? What signs/symptoms have you noticed? How long have these problems been present?(Required)

Has your reptile had any previous problems?(Required)

Yes

If answered yes, please provide details and / or name and number of the veterinarian who has seen your pet:

Has your reptile received any treatment within the last 30 days?

Yes

If answered yes, please provide details such as what was used, what dosage, how often, duration etc. :

Have you noticed any changes in your reptiles behavior?(Required)

Yes

If answered yes, please provide details:

What type of housing is used?

Arboreal

Terrestrial

Aquatic

Size of enclosure(Required)

What is the enclosure made off?

Wood

Fiberglass/Plastic

Metal

Glass

Other

If answered other, please provide details:

Are bathing facilities provided?

Yes

If answered yes, please provide details:

How often is the enclosure cleaned?(Required)

What cleaners / disinfectants are being used?

What heating equipment is used?

Ceramic / Infrared

Spotlight / Bulb

Aquarium Water Heater

Heat Mat

Does your heating equipment have a Thermostat Control?(Required)

Yes

What power is your equipment running on?

If using a heating mat, is it

Under the enclosure

Inside the enclosure

If using other heaters, please provide details here:

Are the heat sources screened from the animal(s)? Please provide details:

Can the animal(s) touch or access the heat source? Please provide details:

Is there additional heating provided inside the enclosure?(Required)

Yes

If answered yes, what type of light is used?

Light Bulb

Fluorescent Light Strip

When was the light last replaced?(Required)

How many hours of light are provided each day?(Required)

What are the daytime temperatures in the hottest/basking and the coolest area?(Required)

What are the nighttime temperatures in the hottest/basking and the coolest area?(Required)

Are these temperatures measured using a thermometer?

Yes

Does anyone in your household smoke?(Required)

Yes

How often do you feed your animal?(Required)

Please indicate which foods are eaten:

Plant Material

Insects

Rodents

If plant material, please select

Vegetables

Flowers

Fruits

Do you feed your plant based food

Frozen / Thawed

Fresh

Other

For your plant based foods, please let us know what amounts ( by weight or approximate volume) and/or what other food entails, and amounts

If you feed insects, please select:

Crickets

Locusts

Mealworms

Waxworms

Earthworms

Other

For your insect based foods, please let us know what amounts ( by weight or approximate volume) and/or what other food entails, and amounts

If you feed rodents, please select:

Mice

Rats

Do you feed your rodents

Frozen / Thawed

Freshly killed

Live Prey

For your rodent based foods, please let us know what amounts you feed

Do you use nutritional supplements? If so, please provide details (what, how much and how often etc.)

How is water provided?(Required)

Bowl

Dripper

Spray

How often do you provide water?

Have you noticed any changes in feeding and/or drinking? If so, please provide details:*(Required)

Have you noticed any changes in waste ( fecal material, urine )? If so, please provide deatails:

Please add any additional comments / information here:

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785-823-2217

1501 South Ohio Salina, KS 67401

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