A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about, you can discuss in more depth with the veterinary staff during your appointment.

Animal Details

Neutered/Spayed?
Origin
Does your reptile have a reproductive history?
Do you have any other reptiles or pets?
Have you or your reptile had contact with any other reptiles in the last 30 days?

Reason for Presentation Today

Have you noticed a change in your reptile's behavior?

Cage Environment

What type of cage is used?
What is the cage made of?
Is there additional ventilation (grills or mesh)?
Are there bathing facilities provided?
What heating equipment is used?
Thermostat Control
Thermostat Control
Thermostat Control
Thermostat Control
Are the heat sources screened from the animal(s)?
Can the animal(s) touch or access the heat source?
Is additional heating provided inside the cage?
If so, what type of light is used?
Are the lights screened from the animals?
Can the animal(s) touch or access the lights?
Is there ever access to direct sunlight (not through plastic or glass)?

What are the daytime temperatures?

What are the nighttime temperatures?

Are these temperatures measured using a thermometer?
Does anyone in the household smoke?
Have there been any changes to the reptile's environment in the last 30 days?

Diet

Indicate which foods are eaten and in what amounts (by number weight or approximate volume)

Plant Material
Insects
Rodents
Do you feed any wild animals to your animal?
Any other food items fed?
Do you use nutritional supplements?
What water supply do you provide?
How is water provided?
Do you use water supplements?
Have you noticed any changes or feeding or drinking?
Have you noticed any changes in waste (fecal material, urine, urates)?
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