Owner Contact Information

Owner name *

First

Last

Phone *

Email *

First Visit
Returning client (new pet)
Returning client/patient

Aquatic Information

Aquatic name *

Age

Birthday (if known)

Color Morph/Variation

Sex *

Male
Female
Unknown

Source of aquatic:

Store
Breeder
Adoption/Rescue
Other

Describe *

Date acquired

Environment/Husbandry

Type of aquarium/environment? *

How many gallons? *

What type of substrate/furnishings do you use?

Are there live plants/coral/snails or any other species in enclosure? *

Yes
No

If yes, please list *

How often do you clean the aquarium/enclosure?

How is the aquarium cleaned?

Water changes? Percent: How often?

Type of filter/filtration system:

What type of lighting do you use?

Is there a heating or chilling system provided? *

Yes
No

If yes, please list *

Indoor vs. Outdoor? Pond vs. Tank?

What is the temperature range? Cool side:

Warm side:

Any recent husbandry changes?

Any new aquatics added to environment recently? *

Yes
No

If yes, how many and what species?

Medical History

Previous illnesses or injuries:

Previous medications:

Any current medications: *

Yes
No

If yes, describe:

History of allergies: *

Yes
No

If yes, to what?

Date of last examination: *

Reproductive History

If female, any history of pregnancy or giving birth? *

Yes
No

If so, when was the last birth? *

How many pregnancies, if known? *

How many were born? *

Current Health Status

Reason for visit: *

Wellness exam (New pet)
Wellness Exam (Return/Annual visit)
Illness/Injury Exam

If ill, describe signs and concerns: *

How long have problems been occurring? *

Has this aquatic been seen for this problem before by a veterinarian?

Yes (At AEAC)
Yes (another practice)
No

If seen at another practice, please name: *

Have you tried treatments prescribed by a veterinarian?

Yes
No

If yes, what? *

Was it helpful?

Yes
No

Have you tried any treatments at home?

Yes
No

If yes, what? *

Was it helpful?

Yes
No

Mark any of the following symptoms seen

Stool color

Other changes/abnormalities:

Any other concerns:

Aquatic History Form