Row concave Shape Decorative svg added to bottom Reptile History Form Reptile History Form Client Information Owner's Name * Owner's Name First Name First Name Last Name Last Name Spouse/Other Spouse/Other First Name First Name Last Name Last Name Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Number Cell Phone Email Animal Details Name or identification Common or scientific species name Date of birth Age Sex M M Neutered F F Spayed Unknown Determined by Probing Endoscopy DNA Visual Unknown OtherOther Origin - Please Select -Breeder/captive bredWild caughtPet storeImportedUnknown How long have you had this animal? From where did you obtain this animal? Does your reptile/amphibian have a reproductive history? - Please Select -YesNo Please give details When did your animal last shed? How often has your animal been shedding? Any trouble shedding? - Please Select -YesNo Do you have any other reptiles/amphibians or other pets? - Please Select -YesNo Please give details Have you or your animal had any contact with other reptiles or amphibians in the last 30 days? - Please Select -YesNo When was the last reptile/amphibian added to your collection? Reason for Presentation Today What is the primary complaint or what signs have you noticed? How long have these problems been present? What health problems has your reptile/amphibian had previously? Has your animal received any treatment in the last 30 days? - Please Select -YesNo Please give details (what was used, dosage, how often, duration) Have you noticed any change in your animal's behavior? - Please Select -YesNo Please give details Have any other animals or persons in the household had any illness in the last 30 days? - Please Select -YesNo Cage Environment What type of cage is used? - Please Select -Arboreal (tail, climbing)TerrestrialAquatic Cage size Where is the cage located? - Please Choose -IndoorsOutdoors Please give details What is the cage made of? Plastic/fiber glass Wooden Metal Glass OtherOther What décor and furnishings are present? Hide box(es) Humidity box(es) Water bowl Branches OtherOther What type of substrate is used? (e.g., coconut byproduct, carpet, gravel, wood shavings, newspaper...) Does the cage have ventilation (grills or mesh)? - Please Select -YesNo Please give size / details Are soaking/bathing facilities provided? - Please Select -YesNo Please give details How often is the cage cleaned? What cleaning/disinfectant agents are used? What percentage of time does your animal spend inside and outside of its cage? Is the animal supervised when out of the cage? What heating equipment is used? Ceramic/infrared Thermostat control?YesNo Spotlight/bulb Thermostat control?YesNo Heat mat Thermostat control?YesNo Aquarium water heater Thermostat control?YesNo Other heaters Are the heat sources protected/screened from the animals? - Please Select -YesNo Please give details Can the animal(s) touch or access the heat source? - Please Select -YesNo Please give details How many hours of heat are provided each day and how? Is additional lighting provided inside the cage? - Please Select -YesNo If yes, what type of light is used? - Please Select -Incandescent light bulbFluorescent strip or coil What is the model and manufacturer? When was the light last replaced? Are the lights protected/screened from the animals? - Please Select -YesNo Please give details Can the animal(s) touch or access the light source? - Please Select -YesNo Please give details How many hours of light are provided each day and how? Is your animal exposed to full spectrum (UVA and UVB) lighting? - Please Select -YesNo How far away from the animal is it located? What is the model and manufacturer? When was the light last replaced? Is there any material (e.g., screening, mesh, glass) between the bulb and the animal? If yes, how many hours per day or per week? Do you measure the humidity in the cage? - Please Select -YesNo If yes what is the humidity level? What are the day-time temperatures? What are the night-time temperatures? Are these temperatures measured using a thermometer? - Please Select -YesNo Does anyone in the household smoke? - Please Select -YesNo Do you use any aerosolized products? - Please Select -YesNo Have there been changes in the reptile's environment in the last 3 months? - Please Select -YesNo Please give details Diet How often do you feed your animal? Where do you feed your animal? Indicate which foods are eaten and in what amounts (by number, weight, or approx.. volume) Vegetables and/or fruits Flowers Other plant material Pellets Insects Live or freeze-dried? Insects, how often fed, type, size and number per feeding Are the insects gut-loaded before they are fed to your animal? - Please Select -YesNo Please give details Rodents - Please Select -Frozen/thawedFresh killedLive Rodents, how often fed, type, size and number per feeding For large carnivores, do you feed other types of small mammals (e.g., rabbits)? - Please Select -YesNo Do you feed your animal any birds or fish? - Please Select -YesNo Please give details Do you feed any wild caught animals to your animal? - Please Select -YesNo Please give details Please give details of any other food items fed Do you use any nutritional (e.g., calcium, multivitamin) supplements? - Please Select -YesNo If yes what, how much, and how often What water supply do you provide? - Please Select -Bottled waterRain/riverWell water How is water provided? Water Storage Bowl Dripper system Direct misting OtherOther How often? How often is the water source changed? Do you use any water supplements? - Please Select -YesNo Please give details Have you noticed any changes in feeding or drinking behavior? - Please Select -YesNo Please give details Have you noticed any changes in droppings (fecal material, urine and/or urates)? - Please Select -YesNo Please give details Submit If you are human, leave this field blank.
