REPTILE/AMPHIBIAN HISTORY FORM - Calgary Avian & Exotic Pet Clinic

Reptile History Form

Full name of Owner/Caregiver (must be over 18 years old):

Phone

Name of pet

Species

Age

Sex

Male Female

Length of time owned

Place of Purchase/Adoption

Background Information

If there are other pets at home (other reptiles, dogs, cats, etc.), please list species, date acquired, and place of purchase/adoption:

Describe brumation history.

Describe breeding history (i.e., eggs laid, etc.).

Husbandry

Please describe your pet’s cage/enclosure including the size of the cage, the material it is made of, location in the home, types of furniture present, if it shares the cage with another pet, how often it is cleaned, and what is used for bedding (i.e., bioactive soil, wood shavings, etc.).

Please describe how often the cage is cleaned and what cleaning products are used.

Please describe what heating equipment is used, what is the temperature range in the enclosure (i.e., basking spot, cool end, etc.) during the day and night, and what type of thermometer is used.

Please describe the humidity in the cage and how humidity is provided.

Please describe the ultraviolet (UV) source including brand of bulb, when it was last replaced, and how often it is replaced.

Please describe your pet’s time outside of the cage including how often it comes out of the cage and for how long, whether or not they are supervised, and where the pet spends its time when out of the cage. Please include whether or not they go outside.

DIET

Please describe in detail your pet’s diet including which foods are eaten and in what amounts. Please include brand names if formulated diets are used.

Please describe what nutritional supplements are used (i.e., calcium, multivitamin), how often they are given, and in what amounts.

Please describe the water source (i.e., tap, bottled, etc.), how it is provided (i.e., bowl, dripper system, spray, etc.), how often it is changed, if a water filter is present, or if the water is treated before it is given to your pet. If done, please provide the results of recent water testing.

Medical History

Please describe your pet’s previous medical history/problems.

If your pet is currently ill, please describe the medical concern in detail including the duration of the problem and if the clinical signs are getting worse, better, or not changing.

If your pet is currently on medications, please give the name of the medication, the reason it has been prescribed medication, and the pet’s response to the medication (i.e., is there improvement?)