Reptile History Questionnaire

    Date:

    Your Name:

    Pet’s Name:

    Species:

    What is the reason for your visit? What are his/her symptoms?

    How long has he/she had this problem?

    Has your pet ever had a problem in the past?
    YesNo

    If so, please describe it in full:

    Housing

    How long have you had your reptile?

    Do you have other reptiles?
    YesNo

    What kind?

    Are they in the same cage as this one?
    YesNo

    Is your pet at room temperature?
    YesNo

    Do you control the temperature and humidity of the cage?
    YesNo

    If so, what is it set at?

    What is on the bottom of the cage? (sand, paper, pebbles, etc.)

    Does your pet get exposed to unfiltered sunlight at least a few days a week? (Not through glass or plastic; screen is ok)
    YesNo

    Do you use a UVA/UVB bulb?
    YesNo

    Is the bulb over 6 months old?
    YesNo

    What is the Wattage?

    Diet

    How much is your Pet eating?
    NothingA littleNormalMore than normal

    When is the last time your pet ate?

    What do you feed your pet?

    Do you gut load (feed supplements) to your pet’s insects?
    YesNo

    How often do you feed your pet?

    How much is your pet drinking?
    NothingA littleNormalMore than normal

    Do you give vitamin/mineral supplements directly?
    YesNo

    How often?

    What kind?

    Shedding and Behaviors

    Is your pet shedding regularly?
    YesNo

    When was the last shed?

    Was it full or partial?
    FullPartial

    Do you mist or soak?
    MistSoak

    If so, how often?

    Are the pet’s droppings normal? If not, describe:

    Additional Information

    Tell us anything else you may feel is important about your pet or the illness.

    In order for our doctors to do a complete analysis for a diagnosis, do we have your permission to perform the following, if needed?

    X-rays ($65):
    YesNo

    Ultrasound ($45):
    YesNo

    *Signature:

    Date:

    Best Contact Phone Number: