Lucks Lane Veterinary Clinic

Amphibian History Form

Form

First Name(required)

Last Name(required)

Pet's Name or Identification(required)

Species(required)

Age(required) *

Sex of Pet(required) *

Origin(required) *

How long have you owned?(required) *

Yes

What is the primary reason you have brought your amphibian here today?(required)

When did the problem or signs begin?(required)

How long has the problem or signs lasted? Have the problems or signs changed in any way?(required)

Have any medications been given or treatments been attempted?(required)

Have there been health problems in the past?(required)

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

Yes

If yes, when:

Yes

What is the cage type?(required) *

What is the cage size?(required)

Cage material:(required) *

How is ventilation provided?(required)

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

List all cage furniture and accessories:(required)

What cleaning methods are used?(required)

What is the frequency of cleaning?(required)

What is the temperature gradient or range?(required)

Are there heat sources?(required)

What is the humidity?(required)

What light sources are provided?(required)

Yes

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?(required)

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

Yes

I don't know

What is the water source?(required) *

Aeration (aging)

Agitation

Activated charcoal filtration

Chemical treatments

What is the frequency of water changes?(required)

How often are filters cleaned or changed?(required)

Yes

If yes, what is the water temperature range?(required)

Yes

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 po

How long are prey items kept with the animal?(required)

Where are the food items obtained?(required)

Please describe the type and frequency of supplimentation.(required)

What is the frequency and timing of feeding?(required)

When did the animal last eat?(required)

Where is food purchased?(required)

If live prey is offered, what care is provided?

For non-aquatic species, how is water provided?

How often is the animal handled?(required)

Yes

I don't know

What breeding practices are utilized?

Have there been recent changes in diet, environment, or husbandry?(required)

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