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Reptile HX Form
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Reptile HX Form
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First Name
*
Last Name
*
Email Address
*
Species
*
Sex
*
Male
Female
M/Neutered
F/Spayed
Unknown
Date of birth
*
Age
*
Origin
Captive bred
Wild (caught or imported)
Unknown
How long have you had this animal?
*
From where did you obtain this animal?
*
When did your pet last shed?
*
Do you have any other reptiles/pets in the household?
*
yes
no
If yes, please list number and species
When was the last reptile/amphibian added to your household?
Has your animal had contact with any other animals in the last 30 days?
*
Yes
No
If yes, when and what species?
Cage location
*
Inside
Outside
What type of cage?
*
Arboreal
Terrestrial
Aquatic
Cage dimensions
*
What is the cage made of?
*
Plastic/Fiberglass
Wood
Metal
Glass
Other
If other, please describe
Is there venilation
*
Yes
No
Have there been any changes in the environment in the last 3 months?
*
Yes
No
If yes, give details
What heating equipment is used?
*
Ceramic/infrared, power
Spot light/bulb, power
Do you use a thermostat control for the heating unit?
Yes
No
What is the wattage?
Heat mat size
*
Mat location
*
Under cage
Inside cage
Aquarium water heater, power
Yes
No
Is the aquarium thermostat controlled?
Yes
No
Other type of heating equipment
Yes
No
Is additional lighting provided inside the cage
*
Yes
No
If yes, what type
*
Light bulb
Fluorescent strip light
Model/Date of last replacement
*
Are the lights screened from the animal?
*
Yes
No
Details
Any exposure to direct sunlight (not through glass/plastic)
*
Yes
No
How many hours of light are provided each day?
*
Yes
No
Do you measure humidity?
*
Yes
No
If yes, what is the humidity?
What are the daytime temperatures (list hottest basking area & coolest area)
What are the nighttime temperatures (list hottest basking area & coolest area)
Any smokers in the house?
*
Yes
No
How often is the cage cleaned?
*
How often do you feed your animal?
*
Which vegetables and fruits are eaten and in what amounts (by weight or approximate volume).
*
Crickets fed daily
*
Locust fed daily
*
Mealworms fed daily
*
Waxworms fed daily
*
Eathworms fed daily
*
List any other insects you feed your pet
Do you feed your insects
*
Yes
No
If yes, what do you feed them?
Rats fed daily
*
Mice fed daily
*
Birds or fish fed daily
*
List any other animals you feed your pet
List nutritional supplements (type & frequency)
What type of water do you supply?
*
Tap
Bottled
Rain or River
How is water provided?
*
Bowl
Drip bottle
Spray
How often is water changed?
*
Do you use water supplements?
*
Yes
No
If yes, please describe
Have you noticed any changes in droppings (fecal material/urine/urates)?
*
Yes
No
If yes, please give details
What is the primary complaint or what signs you have noticed
Has this animal had previous health problems?
*
Yes
No
Details
Has this animal received any treatment in the last 30 days?
*
Yes
No
Details treatment
Have you noticed any change in this animal’s behavior?
*
Yes
No
Details
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