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 UnknownOrigin* Captive bred Wild Caught Import UnknownHow long have you had this reptile/amphibian?*From where did you obtain this reptile/amphibian?*Does this reptile/amphibian have a reproductive history?* Yes NoDetails:*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 NoIf 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 NoIf yes, when and what species?*Cage EnvironmentCage location* Inside OutsideWhat type of cage?* Arboreal Terrestrial AquaticDimensions*What is the cage made of?* Plastic/Fiberglass Wood Metal Glass OtherOther*Is there ventilation* Yes NoVentilation details:*Have there been any changes in the environment in the last 3 months?* Yes NoIf yes, give details:*What heating equipment is being used?* Ceramic/Infrared Spot Light/Bulb Heat mat Aquarium water heater Light bulb Fluorescent strip light OtherOther*Thermostat control?* Yes NoPower __W*Thermostat control?* Yes NoPower __W*Location* Under cage Inside cageThermostat control?* Yes NoPower __W*Is there additional lighting inside cage?* Yes NoModel/Date of last replacement*Are the lights screened from the animal?* Yes NoDetails*Is your reptile/amphibian exposed to full spectrum (UVA/UVB) lighting* Yes NoDetails*Any exposure to direct sunlight (not through glass/plastic)?* Yes NoHow many hours of light are provided each day?*Do you measure humidity?* Yes NoIf yes, what is the humidity?What are the daytime temperatures? (Hottest/Basking Area, Coolest Area)*Are there smokers in the house?* Yes NoDo you use aerosolized substances?* Yes NoHow 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 OtherOther*Amount eaten of each insect?*Rodents* Mice Rats Birds/Fish OtherOther*Amount eaten of each rodent?*Nutritional Supplements - Type/Amount/FrequencyWhat water supply do you provide?* Tap water Bottled water Rain/River waterHow is water provided?* Bowl Dripper System SpraySpray (how often)*How often is the water changed?*Do you use any water supplements?* Yes NoDetails*Have you noticed any changes in feeding or drinking behavior?* Yes NoDetails*Have you noticed any changes in the droppings (fecal material/urine/urates)?* Yes NoDetails*Reason for Presentation TodayWhat is the primary complaint or what signs you have noticed?*Has this reptile/amphibian had previous health problems?* Yes NoDetails*Has this reptile/amphibian received any treatment in the last 30 days?* Yes NoDetails (what was used, often, duration)*Have you noticed any changes in this reptile/amphibians behavior?* Yes NoDetails*Have any other animals or persons in the household had any illnesses within the last 30 days?* Yes NoDetails*Any additional comments or details of relevance?*PhoneThis field is for validation purposes and should be left unchanged.Δ
