Reptile Health Questionnaire Form Owner’s Name Date Address Postal Code Phone numbers (home) (cell) (work) Emerg. Contact(other than immediate family): ph: Email Pet’s Name Breed Colour Sex Male Female Age or Birthday Where did you get your pet and how long have you had him/her? Have other reptiles lived in your new pet’s enclosure? No Yes If yes, what species? Do you have other pets? No Yes If 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 %Other Does your pet get fed in their normal tank/aquarium or elsewhere? Do you leave uneaten/live crickets in the cage? No Yes How 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? No Yes What 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? No Yes Is there a filtration system? No Yes Is a water treatment used? No Yes Are there any hiding places or plants provided? No Yes Do you provide a basking source? No Yes What is the temperature & humidity in the terrarium? Day (temp/humidity) Night (temp/humidity) Is there a temperature gradient in the terrarium? No Yes What heat source do you use? If yes, where is it located? No Yes Do you have a full spectrum/UV light? If yes, where is it located? No Yes Is time spent outside of the enclosure? If yes, is he/she supervised? No Yes Does your reptile hibernate/bruminate? If yes, please describe the duration and change in the environment? No Yes When did your reptile shed last? Has your reptile laid eggs? If yes, when was the last clutch? No Yes Is your reptile sick? If yes, how long has he/she been sick? No Yes Is 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.
