608-835-0551 customerservice@countryviewvets.com

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1350 S Fish Hatchery Rd. Oregon, WI 53575

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Reptile Questionnaire

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:

Book An Appointment

At Country View Veterinary Service of Oregon, we want to be welcoming to people and their pets. We pay attention to your pets’ needs, and understanding your concerns are significant. Please book an appointment for your pet using our online system.

Book Appointment

Have a question?

Get in touch! Complete our online form and we will be in touch with you shortly.

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Location

1350 S Fish Hatchery Rd.
Oregon, WI 53575

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Contact Information

P: 608-835-0551
E: customerservice@countryviewvets.com

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Hours

Mon-Fri: 8:00 AM – 6:00 PM
Sat: 8:00 AM – 2:00 PM
Sun: Closed

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