Reptile & Amphibian History Form

Reptile name or identification:

Common or scientific species name:

Date of birth/Age:

Sex:

Origin:

Captive Bred
Wild Caught/Import
Unknown

How long have you had this animal?

From where did you obtain this animal?

Does your reptile have a reproductive history?

Yes
No

If yes, please give details:

When did your reptile last shed?

How often has your reptile been shedding?

Do you have any other reptiles or pets?

Yes
No

If so, please give details:

Have you or your reptile had any contact with other reptiles in the last 30 days?

Yes
No

If yes, please give details

When was the last reptile added to your collection?

REASON FOR APPOINTMENT

What is the primary complaint or what signs you have noticed? How long have this problems been present?

What health problems has your reptile had previously?

Has your reptile received any treatment in the last 30 days?

Yes
No

If so, please give details:(what was used, dosage, how often, duration?)

Have you noticed any change in your reptile's behavior?

Yes
No

If so, please give details:

Have any other animals or persons in the household had any illness in the last 30 days?

CAGE ENVIRONMENT

What type of cage is used?

arboreal (tall, climbing)
terrestrial
aquatic

Cage size:

What is the cage made of?

plastic/fiberglass
wooden
metal
glass

What decor and furnishings are present?

Is there additional ventilation (grills or mesh)?

Yes
No

Please give size/details:

Are bathing facilities provided?

Yes
No

Please give details:

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

What heating equipment is used?

Ceramic/infrared
Spot Light/Bulb
Aquarium water heater
Heat mat
other (please indicate below)

After selecting heat source please indicate in space below the wattage, and if product is thermostat controlled. If, a heat mat please indicate size and if inside or under cage and if it is thermostat controlled.

please give details:

Are heat sources screened from the animals?

Yes
No

Please give details:

Can the animal(s) touch or access the heat source?

Yes
No

Please give details:

Is additional lighting provided inside the cage?

Yes
No

If so, please give details? (what type bulb or fluorescent strip? Model and Manufacturer?

When was the light replaced last?

Are the lights screened from the animals?

Yes
No

Please give details:

Can animal(s) touch or access the light?

Yes
No

Please give details:

How many hours of light are provided each day?

Is there ever access to direct sunlight (not through glass or plastic)?

Yes
No

If yes, how many hours per day?

Do you measure the humidity in the cage?

Yes
No

If yes, what is the humidity level?

What is the DAY time temperature in the hottest basking aree?

What is the DAY time temperature in the coolest area?

What is the NIGHT time temperature in the hottest, basking area?

What is the NIGHT time temperature in the coolest area?

Are these temperatures measured using a thermometer?

Yes
No

Does anyone in the household smoke?

Yes
No

Do you use any aerosolized products?

Yes
No

Have there been any changes in the reptile's environment in the last 3 months?

Yes
No

If so, please give details

DIET

How often do you feed your animal?

Please indicate which foods are eaten and in what amounts.

Plant Material
Insects
Rodents

by number, weight, or approximate volume:

Do you feed any wild animals to your pet?

Yes
No

If yes, please give details

Any other food items fed? Please give details.

Monday	8:00am – 5:30pm
Tuesday	8:00am – 5:30pm
Wednesday	8:00am – 5:30pm
Thursday	8:00am – 5:30pm
Friday	8:00am – 5:30pm
Saturday	Closed
Sunday	Closed

Reptile & Amphibian History Form