Reptile History Form Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear understanding of your pet's current health status, we need you to fill out the history form below.Today's date Species (SNAKE ONLY):NoneBoa ConstrictorPythonCorn SnakeGarter SnakeRat SnakeOtherSpecies (LIZARD ONLY):NoneIguanaBearded DragonLeopard GeckoUromastyxMonitorOtherSpecies (TURTLE ONLY):NoneBox TurtlePainted TurtleRed Ear SliderTortoiseOther GenderMaleFemaleUnsureIs this your first reptile?YesNoDate of Birth: ActualEstimatedDate Acquired: ENVIRONMENT Cage MaterialGlassPlexiglassPlasticWoodWireOtherIs there a Thermometer in the cage?YesNo Temperature NOTE: Indicate as temperature in °F. NOTE: Indicate as temperature in °F. NOTE: Indicate as temperature in °F.How is the cage heated?Heat LampCeramic HeaterHot RockHeat PadOtherHumidity Level:< 20%20-40%40-60%60-80%> 80% Is there an ultraviolet (UVB) light in the cage?YesNoUnsure Does your pet get natural sunlight?YesNoIs anything (glass / plastic) located between light source & reptile?YesNoSubstrateSandBarkWood ShavingsNewspaperAstroturfOther Please indicate number of inches. Do you soak your reptile?YesNo Is cage shared with another animal?YesNo Describe other cage accessories:NUTRITIONDiet Vitamin & Mineral Supplements:If insects are fed, are they gut-loaded?YesNoNot ApplicableCurrent Appetite:NormalIncreasedDecreasedAnorexicMEDICAL HISTORYPlease list any medical problems:Current treatments or supplements:Please list any previous medical problems:Have you noticed changes in:StoolAppetiteThirstMobility Have you noticed:Weight LossWeight GainVomiting/RegurgitationLimpingSpinal DeformityShedding ProblemsBreathing DifficultyLethargyInactivity Former Vet VisitsYesNo Date of last visit: Records RequestedYesNoRecords Received?YesNoPrevious Lab Tests / Diagnostics:YesNoDate of last testing:Tests Conducted:Complete Blood CountChemistry ProfileFecal ExamBacterial CultureRadiographs (X-ray)Other Tests:Abnormal Results:Results Requested:YesNoSent to Clinic?YesNoYour Signature To the best of my knowledge, the information provided above and on the patient history form is accurate and complete. I authorize you to contact my referring veterinarian if clarification of medical history is needed or to acquire previous veterinary records, I understand that payment is due at the time services are rendered. I agree to pay all charges at the time my pet is discharged.Data Privacy and Consent:I agree to the terms of service