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Reptile History Form

"*" indicates required fields

Client Information

Client First Name*

Client Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Primary Phone*

Email*

Patient Information

Patient Name*

Species*

Breed*

Sex*

Current weight*

Age*

Background Information

Length of time owned*

Where acquired?*

Deparasitized?*

Yes

No

How often handled?*

Daily

Occasionally

Never

If yes, what product?*

Ever taken outside?*

Yes

No

When was last shed?*

If yes, for how long?*

Trouble shedding?*

Yes

No

If yes, please specify*

Husbandry

Type of enclosure*

Size of enclosure*

Location of cage*

Cage furniture*

Cage substrate

Frequency of cage cleaning*

Disinfectant used*

Cage Environment

Light cycle*

Type of lighting*

Heat source*

Humidity level*

Minimum temp in cage*

Maximum temp in cage*

Basking area temp in cage*

Nutrition

Type of food offered*

Amount fed/frequency*

When last fed*

Water source*

List any medications or supplements*

Other General Information

Any other pets?*

Yes

No

Any other reptiles?

Yes

No

If yes, please specify*

Reptiles housed together or singly?*

Together

Singly

Any new additions to the reptile population?*

Yes

No

If singly, where are others located?*

If yes, please specify*

Health Information

Past medical history/problems*

Current presenting problem*

Duration of complaint*

Signature*

Date*

Phone

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