Reptile History Form

First Name*:

Last Name:

Email*:

Reptile name or identification:

Common or scientific species name:

Date of birth:

Age:

Sex:
MFNeutered/SpayedUnknown

Origin:
Captive bredWild caught importUnknown

How long have you had this animal?:

From where did you obtain this animal?:

Does this animal have a reproductive history?:
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When did your animal last shed?:

How often has your animal been shedding?:

Do you have other animals or pets?:
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Have you or your animal had any contact with other animals in the last 30 days?:
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When was the last animal added to your collection?:

What is the primary complaint or what signs have you noticed? 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?:
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Have you noticed any change in your reptile's behavior?:
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Have any other animals or persons in the household had any illness in the last 30 days?:

What type of cage is used?:
Arboreal (tall, climbing)TerrestrialAquatic

What is the cage made of?:
Plastic/FibreglassWoodenMetalGlassOther

What décor and furnishings are present?:

Is there additional ventilation (grills or mesh)?:
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Are bathing facilities provided?:
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How often is the cage cleaned:

What cleaning/disinfectant agents are used:

Are the heat sources screened from the animals?:
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Can the animal(s) touch or access the heat source?:
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Is additional lighting provided inside the cage?:
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What type of light is used?:Light bulbFluorescent strip light

Are the additional heat sources screened from the animals?:
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Can the animal(s) touch or access the additional heat source?:
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How many hours of light are provided each day?:

Is there ever access to direct sunlight (not through glass or plastic)?:
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Do you measure the humidity in the cage?:
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What are the day time temperatures?:

What are the night time temperatures?:

Are these temperatures measured using a thermometer?:
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Does anyone in the household smoke?:
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Do you use any aerosolized products?:
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Have there been changes in the animal's environment in the last 3 months?:
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How often do you feed your animal?:

Insects:
CricketsLocustsMealwormsWaxwormsEarthwormsOthers

Do you feed any wild animals to your animal?:
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Any other food items fed?:
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What water supply do you provide?:
Tap waterBottled waterRain/river water

How is water provided?:
BowlDripper systemSpray

How often is the water changed?:

Do you use any water supplements?:
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Have you noticed any changes in feeding or drinking behavior?:
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Have you noticed any changes in droppings (fecal material, urine and urates)?:
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Any other comments or information: