Aquatic Reptile History Intake Form
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Client Name *
Email *
Phone Number *
Patient Name *
Patient Age *
Appointment Date *
Where did you get your pet and how long ago? *
How do you house your pet?  Describe enclosure (size, materials, ventilation). Include substrate and other objects in the cage (Astroturf, sand, gravel). Please note if your pet has a cage mate. *
How often is their enclosure cleaned?  Please include what cleaning products are used. *
How often do you change the water completely and how often do you do partial water changes? *
Please describe any heat source.  Include brand and wattage, if known, and describe how close your pet can get to the source. *
At what temperature is the water set and how do you monitor it?  Describe any water filtration system in place and how often it is cleaned/changed. *
Do you dechlorinate the water? *
Is there a basking site provided outside the water?  If yes, please describe. *
Do you monitor humidity levels?  If yes, what is the level? *
Please describe all light sources, both natural and artificial.  If you use a UVB bulb, include the type and when it was last replaced. Include how many hours of light exposure your pet receives. *
Do you have other reptiles or pets in the household?  If yes, please list species and if they interact with each other. *
Has there been any contact between humans and reptiles in your household with any other reptiles in the past three months? *
What are you currently feeding your pet? Please provide a detailed list that includes all food (greens, vegetables, fruits, legumes, small rodents, insects). If feeding rodents/insects, are they dead or alive? Are the insects gut loaded? If yes, what do the insects eat? *
How often and where do you offer food? *
Do you add vitamins and supplements?  If yes, what brand and how often? *
How often are the food dishes cleaned? *
When was their last shed and was it normal?  Please describe. *
Does your pet hibernate? If yes, describe temperature range, location and duration. *
Has any reproductive behavior been noted? If yes, please describe *
Has your pet been seen by another vet? If yes, who? *
Is there anything in your pet’s history we need to be aware of? Please list any past illnesses and current medications. *
What prompted today’s visit? If there is an issue, please describe when it began and if the problem tends to happen at a certain time of day/year. *
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