Pre-Register
at Gentle Vet Animal Hospital...
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REPTILE HISTORY FORM
Print this page and fill out before coming
in:
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Reptile's name:________________ Sex: M F Unknown
Species:_______________________
How was the reptile sexed? Visually
Blood test Surgically
Probes
Does the reptile have any specific identification (e.g., tattoo,
microchip)? _________________________
If the reptile is a female, has she produced eggs or given birth in the past? If yes, please
describe:______
_________________________________________________________________________________
Reptile is a: Pet Breeder
How was the reptile acquired? Store Breeder
Other (describe)________________________________
Date acquired:___________________________
Are there any other pets in the house?__________ If yes, please describe, including ages and when acquired:__________________________________________________________________________
When did the reptile last shed its
skin?___________________________________________________
Did the shed appear normal
(describe)?____________________________________________________
Housing
Where is the reptile kept (specify percentage of time in each locations)?
Indoors____________ Outdoors____________ Roam free in house _____________
Describe the reptile's enclosure (i.e., size,
material)__________________________________________
_________________________________________________________________________________
Is the reptile housed alone?________ If no, please
describe:__________________________________
What is/are the heat source(s)?_________________________________________________________
List enclosure temperatures. High temperature (day/night):__________ Low temperature
(day/night):____
Basking site temperatures:_________________
Humidity:_________________
How are heat and humidity measured in the
cage?____________________________________________
What is/are the light source(s) (describe hours of
use)?______________________________________
Is there a UV or full-spectrum light source? Please describe, including hours of
usage:_________________
__________________________________________________________________________________
What substrate and other objects are in the case (e.g., sand, gravel, newspaper, PVC, wood, hiding spots)?
_________________________________________________________________________________
How often is the cage cleaned? Using what
products?_________________________________________
__________________________________________________________________________________
Does the reptile hibernate?_________ if yes, where and for what time
period?_____________________
Has the reptile's environment changed recently? Yes No If yes,
describe:___________________________
Is the reptile ever soaked?_____________ If so, how often?_________________
Where?___________
Diet
What foods are offered to the reptile and in what percentages (e.g., 50% green leafy vegetables, 30%
crickets)?_________________________________________________________________________
Do you supplement the foods with anything such as vitamins? If so, what kind and how
often? __________
If live insects are fed, are they offered food ("gut leaded") before being fed to the
reptile?__________
If so, with what
products?_____________________________________________________________
_________________________________________________________________________________
Are any treats offered? What types? How
often?___________________________________________
Have there been any recent diet changes or new foods? If
yes, describe:_________________________
How is the water offered (e.g., sipper bottle, bowl,
dropper)?__________________________________
Reason for Today's Visit:
What signs have you noticed that prompted today's
visit?______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How long have you noticed the
problem?___________________________________________________
Has the reptile been sick
previously?_____________________________________________________
Has the reptile been seen by any other veterinarian?
If yes, When and why?_______________________
_________________________________________________________________________________
_________________________________________________________________________________
Have any tests been conducted previously on the reptile?
Blood work?________ Fecal Parasite Test?_______ Skin parasite
test? ____X-rays?______________
Other (please
describe):______________________________________________________________
_________________________________________________________________________________
Additional Comments:
_________________________________________________________________________________
_________________________________________________________________________________
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Are you aware that reptiles can carry Salmonella bacteria? If not, please ask us to explain.
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