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): Boa ConstrictorPythonCorn SnakeGarter SnakeRat Snake Species (LIZARD ONLY): IguanaBearded DragonLeopard GeckoUromastyxMonitor Species (TURTLE ONLY): Box TurtlePainted TurtleRed Ear SliderTortoise Gender MaleFemaleUnsure Is this your first reptile? YesNo Date of Birth: ActualEstimated Date Acquired: ENVIRONMENT Cage Material GlassPlexiglassPlasticWoodWireOther Is 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 PadOther Humidity 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? YesNo Is anything (glass / plastic) located between light source & reptile? YesNo Substrate SandBarkWood ShavingsNewspaperAstroturfOther Please indicate number of inches. Do you soak your reptile? YesNo Is cage shared with another animal? YesNo Describe other cage accessories: NUTRITION Diet Vitamin & Mineral Supplements: If insects are fed, are they gut-loaded? YesNoNot Applicable Current Appetite: NormalIncreasedDecreasedAnorexic MEDICAL HISTORY Please 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 Visits YesNo Date of last visit: Records Requested YesNo Records Received? YesNo Previous Lab Tests / Diagnostics: YesNo Date of last testing: Tests Conducted: Complete Blood CountChemistry ProfileFecal ExamBacterial CultureRadiographs (X-ray) Other Tests: Abnormal Results: Results Requested: YesNo Sent to Clinic? YesNo Your 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