Reptile and Amphibian History Form Name or Identification* Common/Scientific species name* Date of Birth* MM slash DD slash YYYY Age* Sex* Male Female Male/Neutered Female/Spayed Unknown Origin* Captive bred Wild Caught Import Unknown How long have you had this reptile/amphibian?* From where did you obtain this reptile/amphibian?* Does this reptile/amphibian have a reproductive history?* Yes No Details:*When did your reptile/amphibian last shed and how often does it shed?*Do you have any other reptiles/amphibians/pets in the household?* Yes No If yes, list the number and species:*When was the last reptile/amphibian added to your household?* Has your pet had contact with any other animals in the last 30 days?* Yes No If yes, when and what species?* Cage EnvironmentCage location* Inside Outside What type of cage?* Arboreal Terrestrial Aquatic Dimensions* What is the cage made of?* Plastic/Fiberglass Wood Metal Glass Other Other* Is there ventilation* Yes No Ventilation details:*Have there been any changes in the environment in the last 3 months?* Yes No If yes, give details:*What heating equipment is being used?* Ceramic/Infrared Spot Light/Bulb Heat mat Aquarium water heater Light bulb Fluorescent strip light Other Other* Thermostat control?* Yes No Power __W* Thermostat control?* Yes No Power __W* Location* Under cage Inside cage Thermostat control?* Yes No Power __W* Is there additional lighting inside cage?* Yes No Model/Date of last replacement* Are the lights screened from the animal?* Yes No Details*Is your reptile/amphibian exposed to full spectrum (UVA/UVB) lighting* Yes No Details*Any exposure to direct sunlight (not through glass/plastic)?* Yes No How many hours of light are provided each day?* Do you measure humidity?* Yes No If yes, what is the humidity? What are the daytime temperatures? (Hottest/Basking Area, Coolest Area)*Are there smokers in the house?* Yes No Do you use aerosolized substances?* Yes No How often is the cage cleaned?* DietHow often do you feed your reptile/amphibian?* Which foods are eaten and in what amounts (Vegetables/Fruits – Type/Amount)*Insects* Crickets Locusts Mealworms Waxworms Earthworms Other Other* Amount eaten of each insect?*Rodents* Mice Rats Birds/Fish Other Other* Amount eaten of each rodent?*Nutritional Supplements – Type/Amount/FrequencyWhat water supply do you provide?* Tap water Bottled water Rain/River water How is water provided?* Bowl Dripper System Spray Spray (how often)* How often is the water changed?* Do you use any water supplements?* Yes No Details*Have you noticed any changes in feeding or drinking behavior?* Yes No Details*Have you noticed any changes in the droppings (fecal material/urine/urates)?* Yes No Details*Reason for Presentation TodayWhat is the primary complaint or what signs you have noticed?*Has this reptile/amphibian had previous health problems?* Yes No Details*Has this reptile/amphibian received any treatment in the last 30 days?* Yes No Details (what was used, often, duration)*Have you noticed any changes in this reptile/amphibians behavior?* Yes No Details*Have any other animals or persons in the household had any illnesses within the last 30 days?* Yes No Details*Any additional comments or details of relevance?*EmailThis field is for validation purposes and should be left unchanged. Δ
