Referring Veterinarian (if applicable):
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Pet's Name (required)
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Species (required)
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Age/DOB/Hatch Date: (required)
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Sex (required)
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Where did you obtain your reptile/amphibian? (required)
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How long have you had your reptile/amphibian? (required)
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Is your reptile/amphibian: (required)
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HOUSING: |
What type of enclosure does your reptile/amphibian live in? (required)
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What are the dimensions? H______________ W_______________ L______________ (required)
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Do you use a hygrometer (humidity meter)? (required)
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If yes, what is the humidity? (Type NA if Not Applicable)
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How is the enclosure heated (e.g., light, heated pad, heat rock)? (Type NA if Not Applicable) (required)
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What is the temperature? Day:______________ Night:_______________ Basking Site:_____________ (Type NA if Not Applicable) (required)
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Do you use thermometers? (required)
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If yes, where are they located? (Type NA if Not Applicable) (required)
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Do you use a full-spectrum UVB bulb? (required)
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If not, what kind of bulb do you use? (Type NA if Not Applicable) (required)
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How often is it replaced and when was the last replacement? (Type NA if Not Applicable) (required)
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How long are the lights on/off: During the day__________________ Off at night__________________ (Type NA if Not Applicable) (required)
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Does your pet spend time outside of the enclosure?: If yes, explain: (Type NA if Not Applicable) (required)
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What is the substrate (bedding)? (Type NA if Not Applicable) (required)
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What is the water source? (Type NA if Not Applicable) (required)
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Are there plants, branches, or other climbing structures? (Type NA if Not Applicable) (required)
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Is there a hiding area? If so, what kind? (Type NA if Not Applicable) (required)
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Are there any other reptiles in the same enclosure? If so, what species? (Type NA if Not Applicable) (required)
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FOR AQUATIC SPECIES: |
How often do you change the water completely? Partially? (Type NA if Not Applicable) (required)
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Do you use a water heater? (required)
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Does the aquarium have a filter? (required)
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Do you test the water quality? (required)
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Diet
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Please fill in the percentage of the total diet and types of food in each category that your pet actually eats:
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Leafy greens:
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Legumes/beans:
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Fruits:
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Other vegetables:
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Insects/small rodents: (select one) (required)
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Pellets:
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Other (including treats):
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How often do you offer food? (required)
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Where do you feed your reptile? (required)
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Do you add vitamin or calcium supplements to the food? (required)
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If you do add vitamins or calcium supplements to the food, what kind/brand and how often? (Type NA if Not Applicable) (required)
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If insects are fed, are they gut loaded? (required)
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Other Information
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Do you soak or bathe your reptile, and if so how often? (Type NA if Not Applicable) (required)
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Do they have any seasonal behavior changes? (required)
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Medical History
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Has your reptile ever been checked for intestinal parasites? (required)
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Has your reptile ever laid eggs? (required)
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How often does your reptile defecate? (required)
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How often does your reptile shed, and when was the last shed? (Type NA if Not Applicable) (required)
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Did your reptile have any problems with their shed? (Type NA if Not Applicable) (required)
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Check any boxes that apply to your pet: (required)
Mites
Wounds
Weight Loss
Weight Gain
Not Defecating
Anorexia
Diarrhea
Shedding Problems
Difficulty Breathing
Lethargy
Inactivity
Increased Appetite
Decreased Appetite
Limping
Vomiting
Deformed Limbs
Swollen Eyes
Other
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Is there anything else you would like us to know today? (required)
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