Reptile History Form – Veterinarians in Winnipeg

Name*

First Last

Phone Number*

Patient Information

Species*

Gender*

Male
Female
Unknown

Date of birth/hatch (or estimated age)*

Date acquired (or how long owned)*

Where did you get your reptile from*

Pet Store
Breeder
Rescue

Environment/Enclosure Information

Type of Enclosure*

Wood/Glass
Glass Tank
Plastic Container
Mesh/Wire Cage

How large is the enclosure?*

What is on the bottom of the enclosure?*

What types of hiding places are provided?*

List species of live plants:*

Is there a soaking/swimming tub?*

Yes
No

Please describe other furnishing:

How often is the cage cleaned, list cleaning products used:

Is your reptile aquatic?*

Yes
No

How often is the water changed?

What type of filter is used?

Do you use a dechlorinator or any othe type of water treatment?

Does your reptile receive sunlight?*

Yes
No

Estimated hours per week of sunlight:

Does the sunlight go through glass or plastice before reaching the reptile?

Yes
No

Artifical lighting:*

Incandescent/screw-in bulbs
Fluorescent/tube blulbs

What is the wattage(s) of your incandescent/screw-in bulbs?

Fluorescent/tube bulb brand

How often are the flourescent bulbs changed? When were they last changed?

Do you have a thermometer in the cage?*

Yes
No

What is the day temperature in the warmest part of the cage?*

What is the day temperature in the coolest part of the cage?*

What is the night temperature in the warmest part of the cage?*

What is the night temperature in the coolest part of the cage?*

What devices are used for heating?*

Hot rock
Heat pad
Heat light
Ceramic heater
Other

Please specify other:

Is there a thermostat?*

Yes
No

Is the cage misted?*

Yes
No

How often?

Is the humidity measured?*

Yes
No

Range

Do you soak your reptie outside the cage?*

Yes
No

Where and how often?

How much time does your reptile spend outside of the enclosure?*

Is you reptile supervised when it is out?*

Always
Sometimes
No

Is supplemental heating provided outside the cage?*

Yes
No

Type

Have you ever noticed your reptile eat any household objects?*

Is the reptile ever taken outdoors?*

Yes
No

Does your reptile hibernate?*

Yes
No

If yes: which months? And where?

Hibernation temperature rage:

How often do you check on them?

Do you have other pets?*

Yes
No

Please list any other pets:

List any recent chages in the envirnoment:*

Diet

What % of the diet conisists of vegetables?*

What % of the diet conisists of fruit?*

What % of the diet conisists of insects, mealworms, etc?*

Are they:

Gut loaded
Dusted before feeding

What % of the diet conisists of rodent, chicks, etc?*

Please list all types and sources

Are they fed

Live
Frozen
Both

What % of the diet conisists of other foods?*

Please describe

Please list any supplements used. How are they given and how often?*

How Often do you feed your reptile?*

Does your reptile eat anything other than is intended diet? (eg. cat food, houseplants)*

How is water offered?*

Dish
Misting
Drip system

Please list any recent additions/changes in the diet:*

When was the last shed?*

Was it:*

One piece
Patchy
Incomplete

Reproductive Information

Do you plan on breeding this animal?*

Yes
No
Possibly

How many clutches/littes has this reptile produced?*

How many live offspring?*

When was the most recent clutch/litter?*

How mant eggs/babies were laid?*

Has your reptile ever had difficulty laying?*

Yes
No

Please describe:

General

Has your reptile ever been tested or treated for internal or external parasites?*

Yes
No
Not sure

Please list dates and medications used:

Previous conditions, problems, surgeries (list with date, if known)*

What are we seeing your reptile for:*

Well pet check-up
Sick

If your reptile is sick, please describe the signs and how long your reptile has been showing these signs:

Is your reptile's general activity level:*

Normal
Decreased
Increased

Is your reptile's appetite:*

Normal
Decreased
Increased

Have you noticed any of the following?*

Weight gain
Weight loss
Discharge from the eyes or nose
Weakness
A change in the droppings
Increased breathing rate or effort
Skin/fecal parasites
Abnormal skin colour or shedding
None of the above

Have you used any medications?*

Has your reptile been seen by another veterinarian?*

Yes
No

When was the most recent visit?

Is there anything else you would like done?

Nail trim
Sexing
Other

Please specify other:

Please include any additional questions or comments in this area: