Aquatic History Form

Please fill out this form completely before your appointment.

Date (mm/dd/yyyy) *

Client's name *

Reason for appointment request *

Fish/Invertebrates/Sharks/Rays in the tank (common name or scientific name) *

Fish/Invertebrates/Sharks/Rays WITH symptoms (common name or scientific name) *

Symptoms *

If other, what symptom is the animal showing? *

How long ago did the symptoms start? *

Have any animals passed away? If yes was a necropsy performed? *

Length of this group of animals in owner care *

Do you have a quarantine program for incoming fish? *

If yes, what is your quarantine protocol? *

Any recent fish introductions? How long ago? *

How long has tank/pond been operating? *

How many gallons in the tank/pond? *

Type of lighting *

Type of water *

How many fish in the tank/pond? *

Any live plants in the in tank/pond? *

Filtration system type: *

Do you test the water quality? *

If yes, How often? *

Temperature of the water in F: *

pH of the water: *

Ammonia/Nitrite/Nitrate Levels (most recent): *

Salinity in SG or ppt (if applicable): *

Water changes- how often in days or weeks? What % of total gallons? *

Types of food fed (brand and types) and frequency: *

Please list any medications or chemicals used in the last 90 days

Are you an aquaculturalist (fish farmer)?

Avian and Exotic Animal Health Center — a full-service mobile veterinary practice dedicated exclusively to exotic pets.