Reptile Questionnaire

Owner Information

Name

Phone number

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Email address

Address

Preferred contact method

Radio options for Preferred contact method

Phone Email

Reptile Information

Reptiles's name

Species

Morph (if applicable)

Age

Sex

Radio options for Sex

Male Female Unknown

How long have you had your reptile?

Where did you acquire your reptile?

Radio options for Where did you acquire your reptile?

Breeder Pet Store Rescue Other

Diet & Nutrition

What type of food do you feed your reptile?

Radio options for What type of food do you feed your reptile?

Live prey Frozen/thawed Fresh Fruits/Veggies Pellets Other

How often do you feed your reptile?

How is food presented?

Please select… Tongs Dish Free roaming Other

Do you offer fresh water daily?

Please select… Yes No

Do you provide any supplements?

Radio options for Do you provide any supplements?

Calcium Multivitamins D3 Other

Housing & Environment

What type of enclosure does your reptile live in?

Please select… Glass PVC Wood Other

What are the dimensions of the enclosure?

What type of substrate is used?

What is the average temperature in the enclosure?

Basking spot, Ambient temperature, Night temperature

How is heating provided?

Please select… Heat lamp Heat map Ceramic heater Other

Do you use UVB lighting?

Please select… No Yes

If yes, provide more information

What type& brand? How often do you change the bulb ?

What is the photoperiod?

Hours of light/dark per day

How often is the enclosure cleaned?

What type of water source is provided?

Please select… Dish Misting Fogger Pool Other

Do you provide environmental enrichment?

Please select… No Yes

If yes, what type?

Hides Climbing Structures Plants Other

Are there other pets in the household?

Please select… No Yes

If yes, what kind?

Behaviour & Activity

Is your reptile handled regularly?

Please select… No Yes

Has your reptile shown any signs of stress or aggression?

Please select… No Yes

Have you noticed any changes in activity levels or behavior?

Please select… No Yes

Health & Medical History

When was your reptile’s last veterinary visit?

Has your reptile ever been diagnosed with any medical conditions?

Has your reptile ever been tested for infectious diseases?

Please select… No Yes

If yes, what type?

Paramyxovirus Adenovirus Other

Has your reptile ever been on any medications?

Please select… No Yes

If yes, please list them

Does your reptile show any of the following symptoms?

Lack of appetite Weight loss Difficulty breathing Regurgitation/Vomiting Diarrhea/Constipation Swelling or lumps Discharge from eyes/ nose/ mouth Changes in skin colour Retained shed Lethargy or weakness Other (please specify below) Check all that apply

More information

If you have selected "Other" above, please let us have more details

Reproductive History

(for applicable species)

Has your reptile ever laid eggs or given birth?

Please select… No Yes

If yes, when was the last time?

Has your reptile shown signs of reproductive issues?

Please select… No Yes

If yes, what kind?

Egg Binding Unusual Behaviours Other

Additional Information

Any other information

Is there anything else we should know about your reptile’s health, behaviour, or environment?

Send