Reptile History Form

Form to be sent to owners of reptile prior to exam for history

Client Name
Client email*
Reptiles Name
Species
Where and when did you get your pet
Do you know the gender of the pet? Is there a reproductive history?
When was the last shed? Was it normal - please describe
Do you have other reptiles in the house? when was the last reptile added to the collection
What is your reptile coming in for? Describe symptoms and duration
Have you provided treatment for your reptile? What did you use?
Have there been behavior changes or previous health problems?
What type of housing is your reptile in?
- Select All
- Glass
- Plastic
- Wood/metal
What size is the cage and what furnishing are present?
Do you have a soaking area?
- Yes
- No
How often do you clean the cage?
How do you clean the cage?
Do you use any lighting? How many hours and what type of light?
what watt lamps are used and when were they changed last?
Is there direct sunlight? How many hours?
What do you use to heat the cage?
- Select All
- Ceramic bulb
- Infrared bulb
- Spot Light
- Bulb Light
- Heat Mat
- Aquatic water heater
Do you use a heat mat? if yes where is it located
Do you use a thermostat?
- Yes
- No
What temperature is the hottest? Basking area?
What temperature is the coolest area?
What substrate do you use on the bottom of the cage?
Do you provide humidity? What do you use? Do you use a hygrometer?
How often do you feed your reptile? What do you feed your reptile?
How often do you change water?
Do you use supplements? Do you gut load insects? Please describe
Are there changes in droppings?
Anything else you would like to tell us?

We look forward to welcoming you to our practice!

3 Jockey Hollow Road,
P.O. Box 208
New Milford, NY 10959

Ph: 845-986-9900

Fax: (845) 986-3212

Monday, Tuesday
9:00 am – 6:30 pm

Thursday, Friday
9:00am – 6:00PM

Wednesday and Saturday
9:00am -12:00 pm