Huntsville Veterinary Specialists & Emergency

Client Information

Your Name(Required)

First Last

Spouse/Other

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Animal Details

Name or identification:

Common or scientific species name:

Date of birth:

MM slash DD slash YYYY

Age:

Sex

Spayed/Neutered

Determined by:

Endoscopy

DNA

Visual

Unknown

Other:

Origin:

From where did you obtain this animal?

How long have you had this animal?

Does your reptile/amphibian have a reproductive history?

Please give details:

When did your animal last shed?

MM slash DD slash YYYY

How often has your animal been shedding?

Any trouble shedding?

Please give details:

Do you have any other reptiles/amphibians or other pets?

Please give details:

Have you or your animal had any contact with other reptiles or amphibians in the last 30 days?

Please give details:

When was the last reptile/amphibian added to your collection?

MM slash DD slash YYYY

Cage Environment

What type of cage is used?

Cage size:

Where is the cage located?

Please give details

What is the cage made of?

Plastic/fiber glass

Wooden

Metal

Glass

Other

What décor and furnishings are present?

Hide box(es)

Humidity box(es)

Water bowl

Branches

Other

What type of substrate is used?

e.g., coconut byproduct, carpet, gravel, wood shavings, newspaper...)

Does the cage have ventilation (grills or mesh)?

Please give size/details

Are soaking/bathing facilities provided?

Please give details

What bedding do you use? Please give details:

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

Please give details

What percentage of time does your animal spend inside and outside of its cage?

Is the animal supervised when out of the cage?

Please give details

What heating equipment is used?

Ceramic/infrared

Thermostat control?

Spotlight/bulb

Thermostat control?

Aquarium water heater

Thermostat control?

Heat mat

Thermostat control?

Where?

Other heaters?

Please give details.

Are the heat sources protected/screened from the animals?

Please give details:

Can the animal(s) touch or access the heat source?

Please give details:

How many hours of heat are provided each day and how?

Is additional lighting provided inside the cage?

What type of light is used?

What is the model and manufacturer?

When was the light last replaced?

MM slash DD slash YYYY

Are the lights protected/screened from the animals?

Please give details:

Can the animal(s) touch or access the light source?

Please give details:

How many hours of light are provided each day and how?

Is your animal exposed to full spectrum (UVA and UVB) lighting?

How far away from the animal is it located?

What is the model and manufacturer?

When was the light last replaced?

MM slash DD slash YYYY

Is there any material (e.g., screening, mesh, glass) between the bulb and the animal?

How many hours per day or per week?

Do you measure the humidity in the cage?

What is the humidity level?

What are the day-time temperatures?

Hottest/basking area:

Coolest area:

What are the day-time temperatures?

Hottest/basking area:

Coolest area:

Are these temperatures measured using a thermometer?

Are there any smokers in the house?

Do you use any aerosolized products?

Have there been changes in the reptile's environment in the last 3 months?

Please give details

Diet

How often do you feed your animal?

Where do you feed your animal?

Indicate which foods are eaten and in what amounts (by number, weight, or approx.. volume):

Vegetables and/or fruits:

Amount & Frequency?

Flowers:

Amount & Frequency?

Other plant material:

Amount & Frequency?

Pellets:

Amount & Frequency?

Insects:

Crickets

Locusts

Earthworms

Mealworms

Waxworms

Others?

Live or freeze-dried?

Insects, how often fed, type, size and number per feeding:

Are the insects gut-loaded before they are fed to your animal?

Please give details:

Rodents

For large carnivores, do you feed other types of small mammals (e.g., rabbits)?

Do you feed your animal any birds or fish?

Please give details:

Do you feed any wild caught animals to your animal?

Please give details:

Please give details of any other food items fed:

Do you use any nutritional supplements?

(e.g., calcium, multivitamin)

What, how much, and how often?

What water supply do you provide?

How is water provided?

How often?

Bowl dripper system, direct misting.

How often is the water source changed?

Do you use any water supplements?

Please give details:

Have you noticed any changes in droppings (fecal material, urine and/or urates)?

Please give details:

Have you noticed any changes in feeding or drinking behavior?

Please give details:

Any other comments or information:

Reason for Presentation Today

What is the primary complaint or what signs you have noticed?

How long have these problems been present?

What health problems has your reptile/amphibian had previously?

Has your animal received any treatment in the last 30 days?

Please give details (what was used, dosage, how often, duration):

Have you noticed any change in your animal's behavior?

Please give details

Have any other animals or persons in the household had any illness within the last 30 days?

Please give details

General Condition and Functioning

Please provide any changes to the following topics:

Appetite and food intake:

Drinking:

Feces and defecation:

Urine and urination:

Behavior, activity, and locomotion:

Any aspects that need further attention:

Date(Required)

MM slash DD slash YYYY

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