Owner Contact Information

Owner name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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

Reptile Information

Reptile name *

Age

Birthday (if known)

Color Morph/Variation

Sex *

Male
Female
Unknown

Source of reptile: *

Store
Breeder
Adoption/Rescue
Other

Describe *

Date acquired

When did your reptile last shed?

How often has your reptile been shedding?

Environment/Husbandry

Reptile is kept in: *

1 Story cage
Free in home/room
Indoors
Outdoors

Size, location and brand of reptile’s enclosure:

Other reptiles in same cage? *

Yes
No

If yes, list names and genders: *

List other reptiles on the premises, past, or present:

Are any of those sick? *

Yes
No

if yes, give details:

Have any passed away? *

Yes
No

if yes, give details:

List other pets in the home or yard:

List toys/hideouts available to the reptile including materials:

What do you use on the bottom of the cage?

Eco carpet
Towels
Other

Eexplain

What heating equipment is used?

Is additional lighting provided inside the cage? Thermostat control? *

Yes
No

If yes, what type of light is used? *

How many hours of light are provided each day? *

Day time temperatures?

Basking area:

Cool area:

Nighttime temperatures?

Basking area:

Cool area:

How often is the bedding/lining changed and or washed?

Frequency of cage cleaning and products used:

Method and frequency of cleaning/changing food and water source:

Sleeping habits: *

Hours of darkness:
Covered
Uncovered

Hours of darkness: *

What is the current diet (Include brands of products):

Protein

Veggies

Other (describe)

Volume of food offered:

Protein

Veggies

Other (describe)

Amount consumed daily:

Protein

Veggies

Other (describe):

How often is food replaced?

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: *

Any previous medical records?

Reproductive History

Has the reptile been spayed or neutered? *

Yes
No

For females, has the reptile ever had a litter of young? *

Yes
No

If yes, when? *

Behavioral History

Any behavioral issues:

Yes
No

Describe *

How long has it been an issue?

Any previous or current treatments for behavioral issues:

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 reptile 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

Characteristics of droppings:

Formed
Diarrhea
Blood
Increased urine

Stool color

Other changes/abnormalities:

Any other concerns:

Reptile History Form