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Patient History Form (Reptile)
Patient Information
Patient Name
First
Breed
Age
Sex
M
F
Unknown
DNA
Chief Complaint/Reason for Visit
Ongoing Conditions
Additional Concerns
Current Medications
Known Allergies
Current Diet
Commercial
Insects
Vegtables
Live
Other
If other, please specify
How Acquired Pet
Hand Reared?
Yes
No
Handled at home?
Yes
No
Caging
Substrate
Time out of Cage?
Date of Last Soaking
Date Format: MM slash DD slash YYYY
How Frequent
Health Information
Cardiovascular/Respiratory
Coughing/Sneezing
Yes
No
Anything produced?
Bubbles or Gurgling
Yes
No
Open Mouth Breathing
Yes
No
Swelling or Redness
Yes
No
Wheezing
Yes
No
Difficulty Breathing
Yes
No
Exercise intolerance
Yes
No
Fainting or Weakness
Yes
No
Retching or Gagging
Yes
No
If other, please specify
Skin
Itching
Yes
No
Location
Date of Last Shed
Yes
No
Location
Normal
Abnormal
Retained Scutes
Yes
No
Visible Parasites
Yes
No
Odor or pigment changes?
Yes
No
Masses or Swellings?
Yes
No
If yes, please describe
If other, please specify
GI/Digestive
Possibility of Foreign Body Ingestion
Yes
No
Feeding Tank separate
Yes
No
Vomiting or regurgitation
Frequency
Describe
Diarrhea or Constipation
Less
Normal
Color change
Normal timing
Watery
Blood
Dry
More
Increased urates
Yes
No
Swelling in abdomen
Yes
No
Describe Feces
Duration of change
Ears
Shaking Head or scratching
Yes
No
Discharge/Odor
Yes
No
If yes, please specify
Swelling
Yes
No
Pain
Yes
No
Heat
Yes
No
Parasites
Yes
No
Head Tilt
Yes
No
Hearing Loss
Yes
No
Which ear
Left
Right
Both
Eyes/Head/Neck
Swelling or asymmetry
Yes
No
Nares or Choanal Discharge
Yes
No
If yes, please describe
Red eye or color change
Yes
No
Describe
Vision Changes
Yes
No
Pain (rubbing or avoiding light)
Yes
No
Allergies
Yes
No
Smoking or Candles around pet
Yes
No
How long has this been noticed
Which eye affected
Left
Right
Both
Musculoskeletal
Difficulty Rising/Jumping/Climbing
Yes
No
Stumbling or Falling
Yes
No
Shaking or Tremors
Yes
No
Bottom of Cage
Yes
No
Non Weight bearing
Yes
No
Dragging toes/legs
Yes
No
Weak Grip or movement
Yes
No
Ongoing issues
Yes
No
If yes, please describe
History of trauma?
Yes
No
If yes, please describe
Onset?
Legs affected
RF
LF
RH
LH
Neurological
Head Tilt or stargazing
Yes
No
Change in attitude or behaviors
Yes
No
If yes, please describe
Seizures
Yes
No
if yes, when was the last seizure?
How many in a month?
Length of Seizure
Medications
Memory loss/confusion
Yes
No
Sudden Blindness or Deafness
Yes
No
Muscle or Grip weakness
Yes
No
If yes please tell us when it started
Oral / Dental
Odor
Yes
No
Growths or Masses
Yes
No
Unexplained swelling
Yes
No
Painful
Yes
No
Difficulty swallowing/eating
Yes
No
Dropping Food
Yes
No
Break Overgrowth or abnormalities
Yes
No
Soft Jaw
Yes
No
Please describe concerns
Reproductive / Cloaca
Sexed
Yes
No
Eggs laid
Yes
No
Previous Clutches
Date
Date Format: MM slash DD slash YYYY
Number of litters
Please enter a number from
0
to
100
.
Problems with laying?
Behavioural Issues?
Pore enlargement/plugged
Yes
No
Cloacal Prolapse
Yes
No
Cloacal Plug
Yes
No
Other concerns
Masses or Growths
Location
Yes
No
If yes, please describe
When did it appear?
History of cancer?
Yes
No
If yes, please describe
Mass growth
Yes
No
Ulceration or bleeding
Yes
No
Bothering pet
Yes
No
Mobile
Yes
No
Diameter of mass
Yes
No
Soft
Yes
No
Hard
Yes
No
Discharge
Yes
No
If yes, please describe
Cage
Location
If yes, please describe
Substrate
If yes, please describe
Temperature
Basking
Gradient
Toys/Perches/Plants
If yes, please describe
Water Source
If yes, please describe
Other Reptiles
Yes
No
Cage Size
Soaking frequency, temperature
Lighting
Spectrum
Last Changed
Unfiltered exposure
Cleaning Frequency
Please describe cleanser
Brumation
Date of brumation
Length of brumation
Humidity
Precentage
Hygrometer
Box
Aquatic Species
Water Change
Frequency
% of water change
Last change
Water source
Water Parameters
Nitrate
Ammonia
Temperature
pH
Timing
Time out of water
Time in water
Able to dry dock patient
Fed in separate tank
Filter
Type of filter
Frequency of cleaning
Dechlorination or other treatments
Please describe
Ongoing History
Detailed description of Diet
Detailed description of Supplements
Additional Information
Today's Date
*
Date Format: MM slash DD slash YYYY
Typed Signature
*
Signature
Consent
*
I agree to the privacy policy.
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New Clients
New Client Registration Form
Patient History Forms
About Us
Services
Patient Resources
Online Pharmacy
Follow Up Survey
Forms
Payment Options
Pet Health
Interactive Animal
Breed Info
Pet Health Library
Videos
Pet Health Checker
Pet Insurance
News
Contact Us
Prescription Refill and Food Order Request Form
Curbside Care Form
