Exotic Reptile & Amphibian History Form

Step 1 of 6 - Patient (Animal) Information

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Client/Owner Name(Required)

Phone(Required)

Patient (Animal) Information

Patient Name or Identification(Required)

Species/Breed(Required)

Origin(Required)

Captive Bred

Wild, Caught Import

Unknown

Date of Birth/Age(Required)

Sex(Required)

Male, intact

Male, neutered

Female, intact

Female, spayed

Unknown

Determined by(Required)

DNA

Endoscopy

Other

Patient (Animal) History

How long have you had this animal?(Required)

From where did you obtain this animal?(Required)

Pet Store

Breeder

Rescue/Sanctuary

Other

Does this animal have any history of breeding or laying eggs?(Required)

Yes

If yes, please describe:(Required)

When did your reptile last shed?

How often does your reptile shed?

Do you have any other pets in the household?(Required)

Yes

Please list the species of the other pets and when they were added to the household(Required)

Species

Added to Household

Has your animal had any contact with any other animals outside your household within the past 30 days?(Required)

Yes

If yes, please describe:(Required)

Cage/Enclosure Environment

What type of cage/enclosure is used?(Required)

Arboreal (Tall, Climbing)

Terrestrial

Aquatic

Other

Please proceed to the next page to provide information about the aquarium environment.

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Non-Aquatic Fields

What are the dimensions/size of the cage/enclosure?(Required)

What is the cage/enclosure made of?(Required)

Plastic/Fiberglass

Wooden

Metal

Glass

Other

Does your animal spend time outside of its’ enclosure?(Required)

Yes

If yes, how often?(Required)

If yes, supervised or unsupervised?(Required)

Supervised

Unsupervised

What is the floor substrate?(Required)

Paper

Corn Cob

Sand

Astroturf

Bark

Other

Is there additional ventilation (grills or mesh)?(Required)

Yes

If yes, please provide size/details:(Required)

Are bathing facilities provided?

Yes

If yes, please provide type/details:

Please attach a picture of the cage/enclosure(Required)

Max. file size: 50 MB.

Please list any décor, furnishing, toys, etc that are present in the cage/enclosure(Required)

Type (i.e bedding, décor, toy, furninshing)

Product Made out of (i.e. plastic, wood, wool)

Brand Name

How often is the cage/enclosure cleaned?(Required)

Daily

Weekly

Bi-Monthly

Monthly

Never

Other

What cleaning products are used?(Required)

Heating Equipment Used:(Required)

Ceramic/Infrared

Spot Light/Bulb

Heat Mat

Aquarium Water Heater

Other

Ceramic/Infrared Power (watts):(Required)

Is the ceramic/infrared heating thermostat-controlled?(Required)

Yes

Ceramic/Infrared Brand (if known):(Required)

Spot Light/Bulb Power (watts):(Required)

Spot Light/Bulb Brand (if known):(Required)

Heat Mat Size:(Required)

Where is the heat mat located?(Required)

Under Cage

Inside Cage

Is the heat mat thermostat-controlled?(Required)

Yes

Heat Mat Brand (if known):(Required)

Aquarium Water Heater Power (watts):(Required)

Is the aquarium water heater thermostat-controlled?(Required)

Yes

Aquarium Water Heater Brand (if known):(Required)

If other heating equipment is used, please describe:(Required)

Is/are the heat source(s) screened from the animal(s)?(Required)

Yes

If yes, please describe how:(Required)

Can the animal(s) touch or access the heat source(s)?(Required)

Yes

If yes, please describe how:(Required)

Is a UVB bulb provided inside the cage?(Required)

Yes

UVB bulb type(Required)

Light Bulb

Fluorescent Strip Light

UVB bulb model/manufacturer(Required)

When was the UVB bulb/light last replaced?(Required)

How many hours of light are provided each day?(Required)

Is there additional lighting provided inside the cage?(Required)

Yes

Additional lighting type(Required)

Light Bulb

Fluorescent Strip Light

Additional lighting model/manufacturer(Required)

When was the additional light last replaced?(Required)

How many hours of additional lighting are provided each day?(Required)

Are the lights screened from the animal(s)?(Required)

Yes

If yes, please describe how:(Required)

Can the animal(s) touch or access the lights?(Required)

Yes

If yes, please describe how:(Required)

Does the animal(s) ever have access to direct sunlight (not through glass or plastic)?(Required)

Yes

If yes, how many hours per day/week?(Required)

Do you measure the humidity in the cage?(Required)

Yes

Average Humidity Level:(Required)

What are the DAYTIME temperatures of the cage/enclosure?

Hottest area / Basking area (Daytime):(Required)

Coolest area (Daytime):(Required)

How are these temperatures measured? (Datyime)(Required)

What are the NIGHTTIME temperatures of the cage/enclosure?

Hottest area / Basking area (Nighttime):(Required)

Coolest area (Nighttime):(Required)

How are these temperatures measured? (Nighttime)(Required)

Does anyone in the house smoke or is the animal around smoke?(Required)

Yes

Do you use aerosolized substances/cleaners/air fresheners?(Required)

Yes

If yes, please list with brand name and frequency of use:(Required)

Brand Name

Frequency of Use

Have there been any changes in the environment in the last 3 months?(Required)

Yes

If yes, please provide details:(Required)

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End Non-Aquatic Fields

Aquarium Environment

Please complete this section only if your animal is an aquatic reptile or a species that requires water as an essential part of its habitat.

What type of aquarium is used?(Required)

Cold Freshwater

Cold Marine

Tropical Freshwater

Tropical Marine

What is the salinity?(Required)

What water source is used?(Required)

Real sea water

Artificial sea water

Fresh tapwater

Other

What type of water change system do you operate?(Required)

Closed (no water change)

Semi-Open (partial water change)

Open (tidal or periodic water change)

How often do you perform Water Changes?(Required)

What percentage of the water is changed?(Required)

Which filtration system(s) do you currently use?

Mechanical filtration (i.e. filter pads, sponges, floss)

Biological filtration (i.e. bio media, ceramic, rings, bio balls)

Chemical filtration (i.e. activated charcoal, resins, phosphate remover)

Mechanical filtration: Type(Required)

Mechanical filtration: Brand(Required)

Mechanical filtration: Frequency changed or replaced(Required)

Biological filtration: Type(Required)

Biological filtration: Brand(Required)

Biological filtration: Frequency changed or replaced(Required)

Chemical filtration: Type(Required)

Chemical filtration: Brand(Required)

Chemical filtration: Frequency changed or replaced(Required)

Do you use ozone?(Required)

Yes

If yes, please describe:(Required)

Do you use protein skimmers?(Required)

Yes

If yes, please describe:(Required)

Do you oxygenate the water?(Required)

Yes

If yes, please describe:(Required)

Please list any décor and furnishings provided in the aquarium, including bottom substrate

Type

Product

Brand Name

Please list any plants that are present

Type of Plant

Was it Quarantined and How

Date it was Added to the Habitat

Is additional lighting provided inside the enclosure?(Required)

Yes

If yes, what type of light?(Required)

Light Bulb

Fluorescent Strip Light

Metal Halide Lamps

Light Bulb: How many?(Required)

Light Bulb: Watts(Required)

Light Bulb: Date Last Replaced(Required)

Light Bulb: Hours of Light Provided Each Day(Required)

Fluorescent Strip Light: How many?(Required)

Fluorescent Strip Light: Manufacturer(Required)

Fluorescent Strip Light: Make/Model(Required)

Fluorescent Strip Light: Date Last Replaced(Required)

Fluorescent Strip Light: Hours of Light Provided Each Day(Required)

Metal Halide Lamps: How many?(Required)

Metal Halide Lamps: Manufacturer(Required)

Metal Halide Lamps: Make/Model(Required)

Metal Halide Lamps: Date Last Replaced(Required)

Metal Halide Lamps: Hours of Light Provided Each Day(Required)

Is there ever access to direct sunlight (not through glass or plastic)?(Required)

Yes

How Many Hours per Day?(Required)

How Many Hours per Week?(Required)

Do you measure any of the following?

Ammonia

Nitrite

Nitrate

Water Oxygen Levels

Ammonia: Method Used(Required)

Ammonia: Last Date of Measurement(Required)

Ammonia: Results(Required)

Nitrite: Method Used(Required)

Nitrite: Last Date of Measurement(Required)

Nitrite: Results(Required)

Nitrate: Method Used(Required)

Nitrate: Last Date of Measurement(Required)

Nitrate: Results(Required)

pH: Method Used(Required)

pH: Last Date of Measurement(Required)

pH: Results(Required)

Water Oxygen Levels: Method Used(Required)

Water Oxygen Levels: Last Date of Measurement(Required)

Water Oxygen Levels: Results(Required)

How often is the aquarium cleaned?(Required)

Daily

Weekly

Bi-Monthly

Monthly

Never

Other

What cleaning products are used?(Required)

Diet/Feeding Regiment

Please list what foods are eaten, how often they are fed, and in what amounts (i.e. weight or approximate volume). Please use the appropriate section for each type of food.

Vegetables

Type

Frozen, Fresh, Freeze-Dried

Amount

Frequency Fed

Fruits

Type

Frozen, Fresh, Freeze-Dried

Amount

Frequency Fed

Flowers

Type

Frozen, Fresh, Freeze-Dried

Amount

Frequency Fed

Insects

Crickets

Locusts

Mealworms

Waxworms

Earthworms

Other

If other insects, please list:(Required)

Frequency Fed (Insects)

Do you gut load your insects?

Yes

What do you use to gut load (i.e. commercial gut loading mix, vegatables, fruits)?(Required)

Do you dust your insects with any supplements?(Required)

Yes

If yes, what supplements?(Required)

Brand

Amount

Frequency Offered

Mice

Type

Number per Feeding

Freshly Killed, Frozen/Thawed, Live Prey

Frequency Fed

Rats

Type

Number per Feeding

Freshly Killed, Frozen/Thawed, Live Prey

Frequency Fed

Other Rodents

Type

Number per Feeding

Freshly Killed, Frozen/Thawed, Live Prey

Frequency Fed

Birds or Fish

Type

Freshly Killed, Frozen/Thawed, Live Prey Amount

Frequency Fed

Other Food Types

Type

Amount

Frequency Fed

Nutritional Supplements

Type

Brand

Amount

Frequency Fed

Do you feed wild animals to your animal(s)?(Required)

Yes

If yes, please describe:(Required)

How is the water offered?(Required)

Bowl

Dripper System

Spray

Bowl Size(Required)

How frequently is the bowl cleaned?(Required)

How frequently do you change the water in the bowl?(Required)

Dripper System Size(Required)

How frequently is the dripper system cleaned?(Required)

How frequently do you change the water in the dripper system?(Required)

Spray Size(Required)

How frequently is the spray cleaned?(Required)

How frequently do you change the water in the spray?(Required)

Do you use any water supplements?(Required)

Yes

If yes, what type?(Required)

Have you noticed any changes or have any concerns about your animal’s feeding or drinking behavior?(Required)

Yes

If yes, please provide details:(Required)

Have you noticed any changes or have any concerns about your animal’s droppings (fecal material, urine and urates)?(Required)

Yes

If yes, please provide details:(Required)

Appointment Information/Reason

Main Reason/Concern for Visit(Required)

Have you noticed any signs, symptoms, or changes in behavior that are concerning?(Required)

Yes

If yes, please list:(Required)

Sign/Symptom

Duration of Sign

Any Treatments Provided

Does this animal have any previous medical or health problems?(Required)

Yes

Have any other animals or persons in the household had any illness within the last 30 days?(Required)

Yes

Has your animal received any treatments/medications in the last 30 days?(Required)

Yes

If yes, please list:(Required)

Medication/Treatment

Dosage

How Often was it Given

Duration

CAPTCHA

Exotic Reptile & Amphibian History Form

Patient (Animal) Information

Patient (Animal) History

Cage/Enclosure Environment

Non-Aquatic Fields

End Non-Aquatic Fields

Aquarium Environment

Diet/Feeding Regiment

Appointment Information/Reason

going beyond the expected