Patient form

Amphibian History Form

First Name *

Last Name *

Pet's Name or Identification *

Species *

Age *

Sex of Pet *

Origin *

How long have you owned? *

Any previous owners? *

Yes No

What is the primary reason you have brought your amphibian here today? *

When did the problem or signs begin? *

How long has the problem or signs lasted? Have the problems or signs changed in any way? *

Have any medications been given or treatments been attempted? *

Have there been health problems in the past? *

Do you own other amphibians? If so, please describe the number of animals and the species housed. *

Have there been any recent introductions of new pets or amphibians? *

Yes No

If yes, when:

Has the amphibian presented today had contact with other animals, particularly in the last 30 days? *

Yes No

What is the cage type? *

What is the cage size? *

Cage material: *

How is ventilation provided? *

What is the cage substrate (what is used to line the bottom of the cage)? *

List all cage furniture and accessories: *

What cleaning methods are used? *

What is the frequency of cleaning? *

What is the temperature gradient or range? *

Are there heat sources? *

What is the humidity? *

What light sources are provided? *

Is full-spectrum UV-B or UV-A lighting used? *

Yes No

How old are the full-spectrum lights? How often are they changed?

How many hours of light are provided daily? How many hours of dark per day? *

How are the heat and light source(s) placed relative to the termometers? *

Have any pesticides, aerosol sprays, or chemicals been used in the immediate vicinity of the reptile environment? *

Yes No I don't know

What is the water source? *

For city or well water, how are chloride or chloramines removed?

Aeration (aging) Agitation Activated charcoal filtration Chemical treatments

What is the frequency of water changes? *

How often are filters cleaned or changed? *

Is the water heated? *

Yes No

If yes, what is the water temperature range? *

Is any type of water testing done? *

Yes No

Nitrite

Nitrate

Dissolved O2

Ammonia

Alkalinity

Hardness

What is the diet? (What is offered and what is eaten?) Include brand names, and be as specific as possible. *

How long are prey items kept with the animal? *

Where are the food items obtained? *

Please describe the type and frequency of supplimentation. *

What is the frequency and timing of feeding? *

When did the animal last eat? *

Where is food purchased? *

If live prey is offered, what care is provided?

For non-aquatic species, how is water provided?

How often is the animal handled? *

Has the animal gone through brumation (hibernation)? *

Yes No I don't know

What breeding practices are utilized?

Have there been recent changes in diet, environment, or husbandry? *

Owner Name *