Calvert Veterinary Center Reptile History Form :
Owner’s Name:
Pet’s Name:
410-360-7297
Date:
1. Patient Information
Species:
Gender:
Date of Birth/Hatch:
Male
Female
unknown
Date acquired:
How big was the reptile when you first acquired it?
Source (pet store, breeder, previous owner):
captive bred
2. Environment
Where is your reptile kept in the house?
Enclosure
Cage(type, size):
What sub-straight 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 other furnishings in the enclosure:
How often is the cage cleaned, what cleaning products are used?
Answer these questions if your reptile is aquatic:
How often is the water changed?
What type of filtration is used?
Do you use a de-chlorinator or any other type of water treatment?
Lighting
Does your reptile receive sunlight?
Estimated hours per week:
Does sunlight pass through glass or plastic before reaching your reptile?
Artificial lighting: incandescent (screw-in bulbs): wattage(s)
hours/day
or wild caught ?
Fluorescent UVB (tube bulbs): brand(s)
hours/day
How often are the fluorescent bulbs changed?
Temperature
Do you have a thermometer(s) in the cage?
What is the temperature in the warmest part of the cage?
What device(s) are used to maintain the temperature?
Warm room
other
heat light
in the coolest part?
Heat rock
ceramic heater
heat pad
aquarium heater
Is there a thermostat on the heating devise?
Is the temperature decreased at night?
by how much
Humidity
Is the cage misted?
how often?
Is the humidity measured?
Range?
How much time does your reptile spend outside the enclosure?
Is your reptile supervised when it is out?
Always
Is supplemental heating provided when outside the cage?
sometimes
no
type
Have you ever noticed your reptile eat house hold objects?
Is your reptile ever taken outdoors?
Does your reptile hibernate?
provide during hibernation.
Do you have other pets?
Describe
Please describe the duration, temperature, and monitoring you
Please list:
List other pets that are kept in the same cage?
Recent acquisitions (new pets within the past 6 months- species, date, source):
Are any of your other pets ill?
List recent changes in environment, if any:
3. Diet
What percent of your reptile’s diet consists of the following (please describe what your reptile actually
eats rather then what is offered) total should = 100%
% Vegetables:
% Fruits:
% Insects, mealworms, etc:
Are they gut loaded or dusted before feeding to your reptile? Describe:
% Rodents, chicks, etc (types/source):
% Pellets, commercial diet or canned food(list types):
% Other, describe:
Please list any supplements used. How are they given and how often?
How often do you feed your reptile/change the food?
Does your reptile eat anything other than its intended diet (ex: cat food, house plants)?
How is water offered (ex: dish, misting, drip system)? How often is fresh water given?
Please list any recent additions/changes in diet:
4. When was the last shed?
Was it normal?
5. Reproductive
Do you plan on breeding your reptile?
Yes
How many clutches/litters has your reptile produced?
When was the most recent clutch/litter?
No
Possibly
How many live offspring?
How many eggs/babies were produced?
6. Has your reptile ever been tested or treated for internal or external parasites? Please describe dates
and medications used:
7. Previous conditions, problems, surgeries (list with dates if known):
8. Is your reptile here for a
well pet check up or a
sick check up?
If your pet is sick, please describe the signs and how long your reptile has been sick showing these signs:
Is your reptile’s general activity level
normal
decreased
increased?
Is your reptile’s appetite
normal
Have you noticed any of the following?
decreased
Weight loss
Discharge from eyes or nose
Weight gain
Increased breathing rate or effort
A change in droppings
Skin/Fecal parasites
increased?
Abnormal skin color or shedding
Weakness
Have you used any medications from a pet store?
9. Has your reptile been seen by another veterinarian for any of the current problems?
If yes, when?
Please list tests performed:
Please list any medications given:
10. Is there anything else you would like done today?
Nail trim
I have other questions about:
Other:
****Did you know that most reptiles carry Salmonella that can infect humans?*****
Please read and keep the attached handout on Salmonella.
Please initial here that you have received this handout