Client Details

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Email Address

Reptile Details

Name

Age (date of birth)

Sex

Date acquired

Source (pet shop, friend, breeder, etc)

Details of Other Pets

Do you have any other reptiles? If yes, please provide details (name, date acquired, source, any known illness)

Do you have any other pets? If yes, please provide details (species, date acquired, source, any known illness)

Husbandry

Does your reptile have access to the entire house? If he/she is confined to one room, please provide details

Is your reptile kept in an enclosure indoors? If yes, please provide approximate dimensions and describe the enclosure

Does your reptile travel or go outdoors? If yes, please specify

How often is your reptile handled?

When was your reptile’s last shed?

Has your reptile had any difficulties shedding in the past?

Has your reptile ever had any difficulties passing urofeces?

Have you noticed any changes in your reptile’s urofeces?

Have you noticed any coughing or sneezing? (If yes, please specify)

Have you noticed any changes in your reptile’s activity? (If yes, please specify)

Have you noticed any changes in behaviour? (If yes, please specify)

Day time temperature of enclosure

Basking time temperature of enclosure

Night time temperature of enclosure

What is the humidity of the enclosure?

What light sources are used? When were lights last changed?

Food

Please describe your reptile's diet

The Presenting Health Concern

Has your reptile had any previous health issues? If yes, please provide details

Please describe your reptile’s clinical symptoms

Has your reptile been seen at another veterinarian for this or any other concerns? (If yes, please provide specifics)

Is your reptile currently taking any medications? (If yes, please describe)

Have you tried any treatments or home remedies in the past? (If yes, please describe)

Any additional comments

Reptile History Form

Client Details

Reptile Details

Details of Other Pets

Husbandry

Food

The Presenting Health Concern

About Us

Regular Clinic Hours

Location

Directions