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Owner's Full Name
Email Address
Phone
Species of Reptile
Age
Sex
Male
Female
Unknown
Purpose
Pet Animal
Breeder
Length of time owned?
Where acquired?
Breeder
Pet Store
Other
If other, please specify
Wild-Caught/Captive-Bred?
Deparasitized? If so, with what?
Is the animal ever taken outside? If yes, please specify.
How often is animal handled?
Daily
Occasionally
Never
Fecal consistency
When was last shed?
Any trouble shedding? If so, please specify.
Husbandry
Husbandry
Type of enclosure
Size of enclosure
Where is the cage located?
Cage furniture
Cage substrate?
Frequency of cage cleaning?
Type of disinfectant used to clean cage?
Cage Environment
Cage Environment
Light cycle
Type of lighting
Heat source
Humidity level
Minimum temperature inside cage
Maximum temperature inside cage
Temperature of basking area
Nutrition
Nutrition
Type of food offered
When were they last fed?
Amount fed/frequency
Supplements/frequency
Water source?
How often is water changed?
Additional Information
Additional Information
Any other pets?
Yes
No
Please specify:
Any other reptiles?
Yes
No
Please specify:
Are the reptiles housed together or singly?
Together
Singly
If not housed together, where are other reptiles located?
Any new additions to the reptile population?
Yes
No
Please specify:
Past Medical History/Problems
Current Presenting Problem
Duration of Complaint
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