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Reptile History Form

Please fill out this form completely before your appointment.

Date (mm/dd/yyyy) *

Client's name *

Pet's name *

What is the reason for the visit?

Preventative care ("check-up") - no health concerns
General Consultation (This type of exam is appropriate for a pet that is exhibiting minor signs of illness, but is not urgently ill)
Recheck

If you have health concerns, please explain what is happening to your pet *

If you don't have any health concerns type n/a.

When did the symptoms start? *

If you don't have any health concerns type n/a.

Any previous medical history that the doctor should be aware of? (Please forward previous records to contact@wildsidevet.com ) *

Is the pet taking any medication? If yes, which medication? Please write the concentration, volume and frequency of the medication *

Will you require refill on any medications during your visit? *

Yes
No

Please know that any refills have to be requested at least 3 business days prior to your visit.

If yes, which one?

Is the pet eating normally? *

Yes
No

If not, please explain:

Is the pet defecating normally? *

Yes
No

If not, please explain:

Is the pet urinating/ passing urates normally? *

Yes
No

If not, please explain:

Is the pet drinking normally? *

Yes
No

If not, please explain:

What is the pet's diet? *

The more detailed information the better!

Do you offer clean water at all times? *

How big is the cage/enclosure? *

Is the cage/enclosure located inside or outside the house? *

Does the animal get fresh air and direct sunlight (without plastic and/or glass between the animal and the sun)? If yes, how many hours a week? *

Do you use any UVB light? If yes, what brand, type and potency? How often do you change it? For how long does it stay on daily? *

Potency: 5.0 or 10.0

Do you use any heating support in the enclosure? If you do, Is it a heat lamp or a heat mat? *

Do you have a thermometer in the basking spot and in the cold side of the enclosure? *

Yes, I have two thermometers, one in the cold side and one in the basking spot
No, I do not have any thermometers
Yes, I have one thermometer in the middle of the enclosure
Yes, I have one thermometer in the basking spot

If you have a thermometer, what is the temperature in the hot side and in the cold side of the enclosure? (°F) *

Do you have a misting system in the enclosure? *

Yes
No

Do you have a dripping system in the enclosure? *

Yes
No

Do you have a hygrometer? If yes, what is the humidity in the enclosure? *

How often and for how long do you soak your pet? *

Does the animal live alone or are there other reptiles in the cage? If yes, which species and sex? *

Are there other animals in the house, if yes, which species? *

Has the pet ever laid any eggs? When was the last time that she layed? How often does she lay? Does she seem to be having trouble laying eggs? *

If you have a male, please write n/a

Are the eggs normal looking? If not, please explain: *

If you have a male, please write n/a

Any other information that you believe it is important for the doctor to know?

Would you like any grooming done during the visit for an extra fee? Please check all that you would like:

Nail trim
Beak trim (for tortoises only, may require sedation)

For water turtles only. What is the potency of the filtration system in the tank?

For water turtles only. How often do you perform a water change? What % of water do you change at a time?

For water turtles only. Do you have a water heater or a thermostat?

For water turtles only. Do you have a thermometer in the water? What is the water temperature?

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

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