608-835-0551
customerservice@countryviewvets.com
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1350 S Fish Hatchery Rd. Oregon, WI 53575
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Reptile Questionnaire
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OWNER INFORMATION
Name:
*
Phone Number:
*
PATIENT INFORMATION
Name:
*
Species:
*
Date of birth/hatch:
*
Gender:
*
Male
Female
Spayed/neutered:
*
Male
Female
How do you know the gender of your reptile?
*
DNA
Surgically
Physical traits
Probe
Ultrasound
Where did you obtain your reptile?
*
Breeder
Pet store
Friend/Family
Rescue
Found/caught
How long have you had your reptile?
*
What other pets are kept in the house?
*
ENVIRONMENT
What type of enclosure does your reptile live in?
*
What is the height of the enclosure?
*
What is the width of the enclosure?
*
What is the length of the enclosure?
*
What type of cage furnishings do you have?
*
Natural branches
Fake branches
Foliage
Real Plants
Stones
Dig box
Water bowl
Hide box
Other
Please explain other:
What is on the bottom of the enclosure?
*
Newspaper
Corn Cob
Kitty Litter
Towel
Tile
Paper towel
Wood shavings/chips
Rubber mat
Indoor/outdoor carpet
Dirt
Moss
Bare gravel
Calci-sand
Play Sand
Other
Please explain other:
What is the day time temperature?
*
What is the night time temperature?
*
What is the basking site time temperature?
*
Do you have a thermostat?
*
Yes
No
Do you have a thermometer?
*
Yes
No
Location of thermometer:
Do you have a hygrometer?
*
Yes
No
How do you heat the enclosure?
*
Light bulbs
Heat cable
Heat tape
Undertank heaters
Hot rock
Ceramic heat emitters
Mercury bulbs
Room heater
Water heater
Other
Please explain other:
What is the humidity of the environment?
*
How do you control the humidity?
*
Humidifier in room
Mister/fogger
Drip system
Spraying
Other
Please explain other:
How is water offered?
*
Dish
Tray
Dropper/mister
Portion of cage
Aquatic
Soaking
Other
Please explain other:
How is water filtered?
*
In-tank filter
Bio-wheel
Canister
None
How often is the water changed?
*
What strength of UVB bulb do you have?
*
2.0
5.0
10.0
How often do you replace your UVB bulb?
*
Does your pet get natural sunlight?
*
Yes
No
How does your pet get natural sunlight?
*
How much natural sunlight does your pet get?
*
How long are the lights on during the day?
*
How long are the lights on during the night?
*
DIET
What do you feed your pet?
*
How often do you feed your pet?
*
How often does your pet defecate?
*
Do you use any vitamin/mineral supplements?
*
Yes
No
What vitamin/mineral do you use?
REASON FOR PRESENTATION TODAY
What are the primary signs you have noticed?
*
How long have these problems been present?
*
What health problems has your pet had previously?
*
Has your pet received any treatment in the last 30 days?
*
Yes
No
If yes, please give detail (what was used, dosage, duration, frequency, etc.)
Have you noticed any changes in your pets behavior?
*
Yes
No
Have any other animals in the household had any illness in the last 30 days?
*
Yes
No
If yes, please describe:
Submit