Client Name:

Reptile's Name:

Email:

Phone:

Species:

Date of Birth/Hatching or Age:

Sex:

Origin:

Where did you obtain this animal?:

How long have you had this animal?:

Does your reptile have a reproductive history?:

When did your reptile last shed?:

How often has your reptile been shedding?

Do you have any other reptiles or pets?:

What kind of reptiles or other pets?:

Have you or your reptile had contact with other reptiles in the last 30 days? If so, give details.

When was the last reptile added to your collection?:

What is your reptile coming in for? If sick, what symptoms is your pet showing and how long have they been present?

Has your reptile received any medications in the past 30 days? If so, what medication and what dosage?:

What health problems has your reptile had previously?

Have you noticed any behavioral changes in your reptile lately?:

Have any other pets or persons in the household had any illnesses in the past 30 days?:

What type of housing is used?:

Cage Size:

What is the cage made of?:

Glass

Plastic/Fibreglass

Wood

Metal

What decor or furnishings are used?:

Is there additional ventilation?(grills/mesh):

Are bathing facilities provided?:

How often is the cage cleaned?:

What cleaning products are used when cleaning cage?:

What heating equipment is used?:

What wattage are the lamps used?:

Are any of the heating units thermostat controlled?:

If you use a heat mat, where is it located? (Under cage, inside cage, etc.)

If you use any other heaters, please give details below:

Can the animal(s) touch the heat sources in any way or is there a screen between to prevent contact?:

Is additional lighting provided inside the cage?:

When was the lamp last replaced?:

Lamp's model & manufacturer:

Can the animal(s) touch the light sources in any way or is there a screen between to prevent contact?:

How many hours of light are provided daily?:

Is there every access to direct sunlight? (not through glass or plastic):

If so, how many hours per day or week?:

Do you measure the humidity in the cage?:

What is the daytime temperature in the hottest (basking) area?:

Coolest area:

What is the nighttime temperature in the hottest (basking) area?:

Coolest area:

Are these temperatures measured with a thermometer?

Does anyone in the household smoke indoors?:

Do you use aerosolized products? (febreze, lysol, etc.)

Have there been any changes in the environment in the past three months?:

How often do you feed your reptile?:

What types of food are fed?:

Vegetables (type & amount fed)

Frozen & thawed or fresh?:

Flowers (type & amount fed):

Frozen & thawed or fresh?:

Fruits (type & amount fed):

Frozen & thawed or fresh?:

Crickets (amount fed):

Mealworms (amount fed):

Waxworms (amount fed):

Locusts (amount fed):

Earthworms (amount fed):

Other insects:

Mice (type & number per feed):

Rats (type & number per feed):

Birds (type & number per feed):

Fish (type & number per feed):

Other rodents:

Are feedings live, freshly killed, or frozen & thawed?:

Are any other foods fed? (if so, please give details):

Do you use any nutritional supplements? If so, what kind, how much, and how often?

What water supply do you provide?:

How is water provided?:

How often is water changed?:

Do you use any water supplements? If so, what kind?

Have you noticed any changed in eating/drinking habits?

Have you noticed any changes in droppings? (fecal material, urine, urates):

Any other comments/information:

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