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Aquatic Animal History Form
Aquatic Animal History Form
Step
1
of
5
- Patient (Animal) Information
20%
Client/Owner Name
(Required)
Phone
(Required)
Patient (Animal) Information
Patient Name or Identification
(Required)
Species/Breed
(Required)
Origin
(Required)
Captive Bred
Wild, Caught Import
Unknown
Date of Birth/Age
(Required)
Sex
(Required)
Male, intact
Male, neutered
Female, intact
Female, spayed
Unknown
Determined by
(Required)
DNA
Endoscopy
Other
Patient (Animal) History
How long have you had this animal?
(Required)
From where did you obtain this animal?
(Required)
Pet Store
Breeder
Rescue/Sanctuary
Other
Do you have any other pets in the household?
(Required)
Yes
No
Please list the species of the other pets and when they were added to the household
(Required)
Species
How Many
Added to Household
Add
Remove
When you acquire a new specie(s), are they quarantined before being introduced to the other specie(s)?
(Required)
Yes
No
If yes, how long are they quarantined?
(Required)
Have you treated with any of the following products?
Formalin, formaldehyde
Potassium Permanganate
Copper
Salt (for freshwater fish only)
Malachite green
Antibiotics (i.e. oxytet, nitrofurazone, sulphonamides)
Antiparasitic drugs (i.e. fenbendazole, metronidazole, praziquantel)
Water Conditioners
Formalin, formaldehyde: Brand
(Required)
Formalin, formaldehyde: Amount
(Required)
Formalin, formaldehyde: How many treatments have been performed?
(Required)
Formalin, formaldehyde: Reason for treatment
(Required)
Formalin, formaldehyde: Date of Last Treatment
(Required)
Potassium Permanganate: Brand
(Required)
Potassium Permanganate: Amount
(Required)
Potassium Permanganate: How many treatments have been performed?
(Required)
Potassium Permanganate: Reason for treatment
(Required)
Potassium Permanganate: Date of Last Treatment
(Required)
Copper: Brand
(Required)
Copper: Amount
(Required)
Copper: How many treatments have been performed?
(Required)
Copper: Reason for treatment
(Required)
Copper: Date of Last Treatment
(Required)
Salt: Brand
(Required)
Salt: Amount
(Required)
Salt: How many treatments have been performed?
(Required)
Salt: Reason for treatment
(Required)
Salt: Date of Last Treatment
(Required)
Malachite green: Brand
(Required)
Malachite green: Amount
(Required)
Malachite green: How many treatments have been performed?
(Required)
Malachite green: Reason for treatment
(Required)
Malachite green: Date of Last Treatment
(Required)
Antibiotics (i.e. oxytet, nitrofurazone, sulphonamides)
(Required)
Type of Antibiotic
Amount Given
Date of Last Treatment
Reason for Treatment
Add
Remove
Antiparasitic drugs (i.e. fenbendazole, metronidazole, praziquantel)
(Required)
Type of Antibiotic
Amount Given
Date of Last Treatment
Reason for Treatment
Add
Remove
Water Conditioners: Brand
(Required)
Water Conditioners: Frequency Provided
(Required)
Water Conditioners: Date of Last Treatment
(Required)
Aquarium Environment
What type of aquarium is used?
(Required)
Cold Freshwater
Cold Marine
Tropical Freshwater
Tropical Marine
What is the salinity?
(Required)
What water source is used?
(Required)
Real sea water
Artificial sea water
Fresh tapwater
Other
What type of water change system do you operate?
(Required)
Closed (no water change)
Semi-Open (partial water change)
Open (tidal or periodic water change)
How often do you perform Water Changes?
(Required)
What percentage of the water is changed?
(Required)
Which filtration system(s) do you currently use?
Mechanical filtration (i.e. filter pads, sponges, floss)
Biological filtration (i.e. bio media, ceramic, rings, bio balls)
Chemical filtration (i.e. activated charcoal, resins, phosphate remover)
Mechanical filtration: Type
(Required)
Mechanical filtration: Brand
(Required)
Mechanical filtration: Frequency changed or replaced
(Required)
Biological filtration: Type
(Required)
Biological filtration: Brand
(Required)
Biological filtration: Frequency changed or replaced
(Required)
Chemical filtration: Type
(Required)
Chemical filtration: Brand
(Required)
Chemical filtration: Frequency changed or replaced
(Required)
Do you use ozone?
(Required)
Yes
No
If yes, please describe:
(Required)
Do you use protein skimmers?
(Required)
Yes
No
If yes, please describe:
(Required)
Do you oxygenate the water?
(Required)
Yes
No
If yes, please describe:
(Required)
Please list any décor and furnishings provided in the aquarium, including bottom substrate
Type
Product
Brand Name
Add
Remove
Please list any plants that are present
Type of Plant
Was it Quarantined and How
Date it was Added to the Habitat
Add
Remove
Is additional lighting provided inside the enclosure?
(Required)
Yes
No
If yes, what type of light?
(Required)
Light Bulb
Fluorescent Strip Light
Metal Halide Lamps
Light Bulb: How many?
(Required)
Light Bulb: Watts
(Required)
Light Bulb: Date Last Replaced
(Required)
Light Bulb: Hours of Light Provided Each Day
(Required)
Fluorescent Strip Light: How many?
(Required)
Fluorescent Strip Light: Manufacturer
(Required)
Fluorescent Strip Light: Make/Model
(Required)
Fluorescent Strip Light: Date Last Replaced
(Required)
Fluorescent Strip Light: Hours of Light Provided Each Day
(Required)
Metal Halide Lamps: How many?
(Required)
Metal Halide Lamps: Manufacturer
(Required)
Metal Halide Lamps: Make/Model
(Required)
Metal Halide Lamps: Date Last Replaced
(Required)
Metal Halide Lamps: Hours of Light Provided Each Day
(Required)
Is there ever access to direct sunlight (not through glass or plastic)?
(Required)
Yes
No
How Many Hours per Day?
(Required)
How Many Hours per Week?
(Required)
Do you measure any of the following?
Ammonia
Nitrite
Nitrate
pH
Water Oxygen Levels
Ammonia: Method Used
(Required)
Ammonia: Last Date of Measurement
(Required)
Ammonia: Results
(Required)
Nitrite: Method Used
(Required)
Nitrite: Last Date of Measurement
(Required)
Nitrite: Results
(Required)
Nitrate: Method Used
(Required)
Nitrate: Last Date of Measurement
(Required)
Nitrate: Results
(Required)
pH: Method Used
(Required)
pH: Last Date of Measurement
(Required)
pH: Results
(Required)
Water Oxygen Levels: Method Used
(Required)
Water Oxygen Levels: Last Date of Measurement
(Required)
Water Oxygen Levels: Results
(Required)
How often is the aquarium cleaned?
(Required)
Daily
Weekly
Bi-Monthly
Monthly
Never
Other
What cleaning products are used?
(Required)
Diet & Nutrition
Select Which Type(s) of Food are Offered and Fed:
Pellets
Brand
Manufacturer
Frequency Offered
Add
Remove
Flakes
Brand
Manufacturer
Frequency Offered
Add
Remove
Plant Produce
Type
Frequency Offered
Add
Remove
Invertebrates
Type
Frequency Offered
Add
Remove
Vertebrates
Type
Frequency Offered
Add
Remove
Other
Type
Frequency Offered
Add
Remove
Nutritional Supplements
Brand
Manufacturer
Frequency Offered
Add
Remove
Appointment Information/Reason
Main Reason/Concern for Visit
(Required)
Have you noticed any signs, symptoms, or changes in behavior that are concerning?
(Required)
Yes
No
If yes, please list:
(Required)
Sign/Symptom
Duration of Sign
Any Treatments Provided
Add
Remove
Does this animal have any previous medical or health problems?
(Required)
Yes
No
Have any other animals or persons in the household had any illness within the last 30 days?
(Required)
Yes
No
Has your animal received any treatments/medications in the last 30 days?
(Required)
Yes
No
If yes, please list:
(Required)
Medication/Treatment
Dosage
How Often was it Given
Duration
Add
Remove
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going beyond the expected
