Reptile Health Questionnaire Form Owner’s NameDateAddressPostal CodePhone numbers (home)(cell)(work)Emerg. Contact(other than immediate family):ph:Email Pet’s NameBreedColourSexMaleFemaleAge or BirthdayWhere did you get your pet and how long have you had him/her?Have other reptiles lived in your new pet’s enclosure?NoYesIf yes, what species?Do you have other pets?NoYesIf yes, what species and do they have contact with this reptile?Where do you buy your pet’s food?How often is he/she fed?Insects%Worms%Fruit%Vegetables%OtherDoes your pet get fed in their normal tank/aquarium or elsewhere?Do you leave uneaten/live crickets in the cage?NoYesHow do you give vitamins/calcium supplement and what brand of supplement do you use?How often do you give vitamin/calcium supplement?Is your reptile in a cage/terarium? If yes , how large is it?NoYesWhat substrate (bedding) do you use?How often do you change/clean the cage and what do you use to clean the cage?Is there a water source? If yes, how often is it cleaned?NoYesIs there a filtration system?NoYesIs a water treatment used?NoYesAre there any hiding places or plants provided?NoYesDo you provide a basking source?NoYesWhat is the temperature & humidity in the terrarium? Day (temp/humidity)Night (temp/humidity)Is there a temperature gradient in the terrarium?NoYesWhat heat source do you use? If yes, where is it located?NoYesDo you have a full spectrum/UV light? If yes, where is it located?NoYesIs time spent outside of the enclosure? If yes, is he/she supervised?NoYesDoes your reptile hibernate/bruminate? If yes, please describe the duration and change in the environment?NoYesWhen did your reptile shed last?Has your reptile laid eggs? If yes, when was the last clutch?NoYesIs your reptile sick? If yes, how long has he/she been sick?NoYesIs your reptile showing any of these signs of illness? change in appetite change in stools weakness breathing difficulty swelling discharge from eyes/nose constipation abnormal behaviour other Do you have any other health issues or concerns you would like to discuss with the veterinarian?PhoneThis field is for validation purposes and should be left unchanged.