Reptile & Amphibian History Form Required Fields in Red ANIMAL DETAILS Reptile Name or Identification: Common / Scientific Species Name: Date of Birth: Age: Sex: MM/NeuteredFF/SpayedUnknown Origin: Captive bredWild caught importunknown How long have you had this animal? From where did you obtain this animal? Does your reptile have a reproductive history? YesNo Please give details: When did your reptile last shed? How often has your reptile been shedding? Do you have any other reptiles or pets? YesNo Please give details: Have you or your reptile had any contact with other reptiles in the last 30 days? YesNo Please give details: When was the last reptile added to your collection? REASON FOR PRESENTATION TODAY What is the primary complaint or what signs have you notice? How long have these problems been present? What health problems has your reptile had previously? Has your reptile received any treatment in the last 30 days? YesNo Please give details (what was used, dosage, how often, duration?) Have you noticed any change in your reptile's behavior? YesNo 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)TerrestrialAquatic Cage size: What is the cage made of? Plastic/FibreglassWoodenMetalGlass Other Material: What décor and furnishings are present? Is there additional ventilation (grills or mesh)? NoYes Please give size/details: Are bathing facilities provided?? NoYes Please give details: How often is the cage cleaned? What cleaning/disinfectant agents are used? What heating equipment is used? Ceramic/infrared NoYes Power in Watts Thermostat Control NoYes Spotlight/bulb NoYes Power in Watts Thermostat Control NoYes Heat mat NoYes Size Where? Under CageInside Cage Thermostat Control? NoYes Aquarium water heater NoYes Power in Watts Thermostat Control NoYes Other heaters, please give details: Are the heat sources screened from the animals? NoYes Please give details: Can the animal(s) touch or access the heat source? NoYes Please give details: Is additional lighting provided inside the cage? NoYes If yes, what type of light is used? Light bulbFluorescent strip light What is the model and manufacturer? When was the light last replaced? Are the lights screen from the animals? NoYes Please give details: Can the animals touch or access the lights? NoYes Please give details: How many hours of light are provided each day? Is there ever access to direct sunlight (not through glass or plastic)? NoYes If yes, how many hours per day or per week? Do you measure the humidity in the cage? NoYes If yes, what is the humidity level? What are the day time temperatures? Hottest area, basking area Coolest area What are the night time temperatures? Hottest area, basking area Coolest area Are these temperatures measured using a thermometer? NoYes Does anyone in the household smoke? NoYes Do you use any aerosolized products? NoYes Have there been changes in the reptile's environment in the last 3 months? NoYes Please give details: DIET How often do you feed your animal? Indicate which foods are eaten and in what amounts (by number, weight, or approx volume): Plant material: If Vegetables, type & amount per feed: Frozen/thawedFreshOther If Flowers, type & amount per feed: Frozen/thawedFreshOther If Fruits, type & amount per feed: Frozen/thawedFreshOther Insects: Crickets Locusts Mealworms Waxworms Earthworms Others Rodents: Type and number of mice per feed: Type and number of rats per feed: Birds or fish, please give details: Were they freshly killed / Frozen / thawed / Live? Please give details Do you feed any wild animals to your animal? NoYes Please give details Any other food items fed? Please give details: Do you use any nutritional supplements? NoYes If yes what, how much, and how often: What water supply do you provide? Tap WaterBottled WaterRain/river Water How is water provided? BowlDripper SystemSpray How often: [waterProvDetails] How often is the water changed? [waterChangeDetails] Do you use any water supplements? NoYes Please give details: [waterSupplementDetails] Have you noticed any changes in feeding or drinking behavior? Please give details Have you noticed any changes in droppings (fecal material, urine and urates)? Please give details: Any other comments or information:
