Reptile History Form

Owner's first and last name(Required)







Pet's Name(Required)




Common/Species Name(Required)




What is your pets origin?(Required)



Please select your pets sex:(Required)



Does your reptile have a reproductive history?


Do you have any other reptiles or pets?(Required)


Have you or your pet have contact with any other reptiles in the last 30 days?(Required)


Has your reptile had any previous problems?(Required)


Has your reptile received any treatment within the last 30 days?


Have you noticed any changes in your reptiles behavior?(Required)


What type of housing is used?



What is the enclosure made off?





Are bathing facilities provided?


What heating equipment is used?




Does your heating equipment have a Thermostat Control?(Required)


If using a heating mat, is it


Is there additional heating provided inside the enclosure?(Required)


If answered yes, what type of light is used?


Are these temperatures measured using a thermometer?


Does anyone in your household smoke?(Required)


Please indicate which foods are eaten:



If plant material, please select



Do you feed your plant based food



If you feed insects, please select:






If you feed rodents, please select:


Do you feed your rodents



How is water provided?(Required)