Pre-visit Questionnaire Reptile/Amphibian Pre-Visit Questionnaire Form in Canton Pre-Visit Questionnaire Email * What would you like to address at this visit? * Species/breed * Gender (if known) * Where did you obtain your reptile? * How long have you had your reptile? * Describe the enclosure environment (flooring substrate, size tank, etc). * What lighting is provided? Is there UVB? * How often is the UV bulb changed? * What heat sources are provided during the day? * What heat sources are provided at night? * What are the temperatures on the cool side, warm side, and basking areas? * What is the humidity? * What does your reptile eat? * How often? * When is the last time he/she ate? * If feeding insects, are they gut-loaded? * Is live food left in cage if uneaten? * What supplements are added (be as specific as possible), and how often? * What water source is provided? * If applicable, when was the last shed, and how did it go? * If female, has she laid eggs? When or how often? * For aquatic species only, how is the water treated and cleaned? * For aquatic species only, what is the water temperature? * Any previous medical history? * Is your reptile experiencing any of the following symptoms Change in quantity or consistency of stool * Yes No Lethargy/weakness * Yes No Eye problems * Yes No Lameness * Yes No Distended abdomen/bloated * Yes No Difficulty breathing * Yes No Not eating/eating less * Yes No Coughing/sneezing * Yes No Regurgitating * Yes No Discharge from eyes or nose * Yes No Sores or swelling of limbs * Yes No Difficulty Shedding * Yes No Sores or swelling around mouth * Yes No Captcha Submit If you are human, leave this field blank.
