Reptile Husbandry Form Please fill out our Reptile Husbandry Form provided below. If you need help or have any questions, please call us at (215) 995-4049. Reptile Husbandry Form Reptile Husbandry Form Please Select One * I elect CPR My pet is a DNR Client Name * Client Name First First Last Last Date * Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal We regularly post photos of our patients to our social media, both for education and for fun! Do you give us permission to post photos of your pet? * YES, I give permission to post photos of my pet(s) NO, please do not post my pet(s) on social media How did you hear about our clinic? * Current clientCurrent client Social MediaSocial Media Website Veterinary Emergency Group (VEG) OtherOther Is your pet covered by an insurance plan? * Yes No Insurance Information Is this a referral? * Yes No Regular DVM/Hospital? * Regular DVM Hospital OtherOther An accurate history of your pet is extremely important and allows your pet healthcare team to provide thorough care. Please provide the following information. Patient Information Patient Name * Species * Sex Select OneMaleFemaleUnknown Date of birth/hatch (if known) Location/State of birth Date acquired How big was your pet when you first acquired them? Have they grown since you acquired them? Yes No Source Pet Store Breeder Previous Owner Captive bred or wild caught? Captive Bred Wild Caught Number of Previous Owners (other than breeder/store) 1 2 3+ What other states and countries has your pet lived in? Environment Where is your pet kept in the house? Enclosure (type, size) What is on the bottom of the enclosure? Please describe What types of hiding places are provided? Is enrichment provided? Yes No Please describe List species of live plants in enclosure Is there a soaking/swimming tub? Yes No Please describe Please describe any other furnishings How often is the enclosure cleaned, and what cleaning products are used? Is this a bioactive terrarium/paludarium? Yes No What substrate layers are used? How often is the substrate changed? When was the last time the enclosure was changed? How long did you cycle the terrarium/paludarium prior to introducing your pet? What species make up your bioactive clean-up crew? Is your pet an aquatic species? Yes No Section How often is the water changed? What type of filtration is used? Do you use a dechlorinator or any other type of water treatment? Yes No Please describe Water Quality What were the results of your last water quality test? pH Nitrite Nitrate Ammonia Type of kit used How often is the water tested? Lighting Does your pet receive sunlight? Yes No Estimated hours per week Does the sunlight pass through glass or plastic before reaching your pet? Yes No Artificial lighting in enclosure / living space Do you use incandescent ("screw-in" bulbs)? Yes No Brand/Wattage(s) Hours per week Do you use fluorescent (tube bulbs)? Yes No Brand/Wattage(s) Hours per week How often are the fluorescent bulbs changed? Do you use HID or mercury vapor bulbs? Yes No Brand/Wattage(s) Hours per week Do you use LED (housing unit bulbs)? Yes No Brand/Wattage(s) Hours per week How often are the bulbs changed? Temperature/Humidity Do you have a thermometer(s) in the cage? Yes No What is the mean temperature? What is the temperature at the warmest part of the cage? What is the temperature at the coolest part of the cage? What device(s) are used to maintain the temperature? Hot rock Warm heat Ceramic heater Heating pad Heat light Aquarium heater OtherOther Is there a thermostat? Yes No Does the temperature decrease at night? Yes No By how much? Is the cage misted? Yes No How often? Is the humidity measured? Yes No What is the range? Is there a humidity hide? Yes No How often is this cleaned or changed? Please describe How much time does your pet spend outside of the enclosure (average hours / day)? Is your pet supervised when out? Always Sometimes New Option Is supplemental heating provided outside the cage? Yes No What type of heating is it? Does your pet eat objects or cage material? Yes No Please describe Is your pet ever taken outside? Yes No Please describe Has your pet consumed outdoor insects, animals, or objects? Yes No Please describe List recent changes in the environment, if any Does your pet hibernate? Yes No Please describe the duration, temperature, and monitoring that you provide during hibernation Other Pets If you have acquired any new pets within the past 6 months, please provide species, date, and source Do you have other pets? Yes No Please list them below Are any of your other pets ill? Yes No Please describe Diet What percent of your pet’s diet consists of the following (please describe what your pet actually eats, rather than what is offered) Vegetables, fruits, greens Insects, mealworms, etc Types/brand(s) Types/brand(s) Are they "gut loaded" or dusted before feeding to your pet? Yes No What is it dusted with? Rodents, chicks, etc. Pellets, commercial diet, or canned food How are they fed? Live Killed Both Types/brand(s) Other Please describe How often do you feed your pet? Is your pet eating/drinking normally? Yes No Please list any supplements used, as well as how they are given and how often Does your pet eat anything other than its intended diet (e.g. the cat's food, houseplants)? Yes No Please describe How is water offered (e.g. dish, misting, drip system)? Has there been any recent additions/changes in the diet? Yes No Please describe Shedding When was the last shed? Was it normal? Yes No Please describe Reproductive Do you plan on breeding your pet? Yes Maybe No How many clutches or litters has your pet produced? If the answer is none please skip to the next page When was the most recent clutch or litter? How many eggs or babies were laid? Were the offspring healthy? Yes No Please describe Has your reptile ever had difficulty laying? Yes No Please describe Prior Medical History Has your pet ever been tested or treated for internal or external parasites? Yes No Please describe Has your pet had any other prior conditions, problems, or operations (list with date, if known)? Is your pet here for A wellness check up (ie, no health concerns)? A sick / unhealthy evaluation with health concerns? Section Describe the signs and how long your pet has been showing these signs Please indicate your pet's general activity level Decreased Normal Increased Please indicate your pet's general activity level Decreased Normal Increased Have you used any medications from a pet store? Yes No Please describe Have you noticed any of the following? Weight loss Weight gain Discharge from the eyes or nose Increased breathing rate or effort A change in the droppings Abnormal skin color or shedding Parasites on the skin or in the feces Weakness Other Veterinary Care Has your pet been seen by another veterinarian for any of the current problems? Yes No When was your pet seen? Please list tests performed Please list medications given Last date medications were administered Is there anything else you would like done today? Nail trim OtherOther Photo of pet Upload Drop a file here or click to upload Choose File Maximum file size: 52.43MB Captcha Submit If you are human, leave this field blank.
