Brealey Drive - Reptile History Form
Please tell us more about your reptile! If you are completing this form for multiple reptiles of the same species, please complete one form in its entirety and in any additional forms answer "same as first reptile's name" for any information that is the same between them. Thank you for taking the time to complete this form, it will be very beneficial to us when providing care to your reptile! If you have any questions regarding this form please call the clinic at 705-741-2322 or send an email to info@brealeydriveanimalclinic.com

**PLEASE NOTE** THIS FORM IS NOT AN APPOINTMENT REQUEST. If you are a new client, please contact the clinic first to set up an account. This form is not monitored daily.
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When coming in for your appointment please bring a heat source for your reptile.
 (oat bag, hot water bottles, etc.)
Please Also Send Photos Of Your Reptile's Enclosure!
photos can be sent to our email info@brealeydriveanimalclinic.com
Client Information
Client Name: *
Phone Number on File: *
Patient Information
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
Reptile's Name: *
Species: *
Age: *
Sex: *
Required
Length of time owned: *
Where was your reptile acquired?  *
Required
Any additional background information:
Reason for Visit
If reason for visit is just a general health exam or check up, please state this in "primary reason for visit" and answer "N/A" when necessary.
What is the primary reason for your reptile's visit?  *
How long has this concern been present?
Reptile History
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
Has your reptile had any other health problems previously? (YES/NO) If YES, please describe: *
Has your reptile been seen by another veterinarian previously? (YES/NO) If YES, what clinic? When/why? *
Have any tests been conducted previously on your reptile (bloodwork, fecal parasite tests, skin parasite tests, x-rays, other)? (YES/NO) If YES, please list tests conducted and results if known: *
When was your reptile's last shed? *
Has your reptile had any troubles when shedding? (YES/NO) If YES, please specify: *
Is your reptile producing normal droppings (bowel movements)? (YES/NO) If NO, please describe: *
What is the frequency of your reptile's bowel movements? *
Housing
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
Type of enclosure: *
Size of enclosure: *
Where is the enclosure located? *
Enclosure substrate: *
Objects in enclosure: *
How often is the enclosure cleaned? *
What type of products/disinfectants are used when cleaning the enclosure? *
Do you have other reptiles in your household? (YES/NO) If YES, please describe: *
Is your reptile housed with any other reptiles? (YES/NO) If YES, please describe (how many, how long, etc.): *
What is your reptile's light cycle? *
Types of lighting: *
What heat sources are used? *
What is the humidity level? *
Is there a UV or Full-Spectrum lightbulb? If so, how often is the lightbulb changed? *
What is the minimum temperature in the enclosure? *
What is the maximum temperature in the enclosure?
 *
What is the basking temperature in the enclosure?
 *
Is your reptile ever soaked/misted with water? (YES/NO) If YES, how often? *
Nutrition
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
What types of food are offered to your reptile? *
What is the amount of each type of food being offered to your reptile? *
How often is your reptile fed? *
If insects are being offered, are they offered food ("gut-loaded") before being fed to your reptile?
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If YES what are the insects fed?
Are there any other vitamin or mineral supplements being offered to your reptile? (YES/NO) If YES, please describe (brand, purpose, amount, frequency, etc.): *
Have there been any recent diet changes or new foods being offered to your reptile? (YES/NO) If YES, please describe: *
What is your reptile's water source? *
Is there any additional information you feel we should know about your reptile?
Thank you again for taking the time to complete this form. Don't forget to send a photo of your reptile's enclosure to our email. We look forward to seeing you and your reptile!
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