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Home » Forms » Reptile History Form

Reptile History Form

"*" indicates required fields

Date*

MM slash DD slash YYYY

Name of pet*

Species*

Age

Sex*

Male

Female

Is this a pet or are you a breeder?*

Pet Animal

Breeder

Background Information

Length of time owned*

Where was the pet acquired?*

Breeder

Pet Store

Other

If other, please specify*

Wild-caught/Captive bred?*

Deparasitized?*

Yes

No

If yes, with what?*

How often is animal handled?*

Daily

Occasionally

Never

Animal ever taken outside?*

Yes

No

If yes, for how long?*

When was last shed?*

Any trouble shedding?*

Yes

No

If yes, specify*

Fecal consistency?*

Husbandry

Type of enclosure*

Size of enclosure*

Where is cage located?*

Cage furniture*

Cage substrate?*

Last change*

Frequency of cage cleaning?*

Type of disinfectant used to clean cage?*

Cage Environment

Light cycle*

Type of Lighting*

Last change*

Heat source*

Humidity level*

Location of heat*

How measured*

Temperateure within cage*

Minimum, Maximum, Basking area

Nutrition

Type of food offered*

If feeding insects*

Gut load

Dust

Other

If Other, please specify*

Source of insects*

Amount fed/frequency*

When was the animal last fed*

Water source*

Most recent water change*

Supplements

Any other pets?*

Yes

No

If yes, please specify*

Any other reptiles?*

Yes

No

If yes, specify*

Reptiles are housed together or apart?*

If not housed together, where are other reptiles located?*

Any new additions to the reptile population?*

Yes

No

If yes, specify*

Past medical history/problems

Current presenting problems*

Duration of complaint*

Any behavioral changes?*

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Comments

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Lake Huron Veterinary Clinic

1825 Pine Grove Ave,
Port Huron, MI 48060

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