Office Use Only Animal #: Program Entrance Date: Staff: Facilitated Adoption Profile Herptile Owner Name: Date: Address: Phone Number E-mail: Herptile s name: Does he/she respond to his/her name? Yes No Reason for Rehoming: 1. How old is your herptile? 2. How long have you had your herptile? 4. Your herptile s sex: Male Female Unknown 5. Do you have proof of your herptile s sex? Yes No 6. What species is your herptile?: 7. What subspecies/breed?: 8. How did you acquire your herptile? Pet store Friend/Family Newspaper/Internet Gift Stray Shelter/Rescue Group: Breeder: Other: 9. How old was your herptile when you acquired him/her? 10. What is your herptile accustomed to eating? Fresh greens Fresh vegetables Fresh fruits crickets meal worms wax worms silk worms butter worms Earthworms Other insects: Pinkies Fuzzies Hoppers Rat pups Sm rats Md rats Lrg rats Other rodents: Pellets Feeder fish Shrimp Freeze dried shrimp Freeze dried krill Other freeze dried items: 11. Animal/insect food is fed: live fresh-kill thawed from frozen freeze dried 12. How often does your herptile eat animal/insect food? How much is offered? 13. How often does your herptile eat pelleted food? How much is offered?
14. How often does your herptile eat vegetables/fruit? How much is offered? 15. What brand(s) are you feeding? 16. What supplements are you offering? 17. What treat(s) are you offering? 18. When was the last time your herptile ate? How much was consumed? 19. Comments: Living Habits 20. My herptile is used to living in: apartment/condo house garage balcony outdoor enclosure/pond 21. The room my herptile is kept: basement living room kitchen child s bedroom adult s bedroom spare room 22. My herptile s enclosure is: a cage a terrarium an aquarium a pond other: 23. The dimensions of my herptile s enclosure are: 24. The substrate (ground cover) my herptile is used to in the enclosure is: 25. The heat source(s) my herptile is used to is: 26. The temperature the enclosure is kept at in the daytime is: 27. The temperature the enclosure is kept at in the nighttime is: 28. The lighting my herptile is used to is: 29. The light cycle for the enclosure is: 30. The humidity the enclosure is kept at is: 31. The water setup for my herptile is: 32. Other special housing needs for my herptile: 33. My herptile comes out of the enclosure: every day once/week rarely never 34. The length of time my herptile is out: 5-15 min 15-30 min 30-60 min 1-2 hrs 2-4 hrs 4-8 hrs 8-12 hrs 12 hrs + free-range:
35. My herptile is allowed on: all furniture some furniture no furniture 36. My herptile s destructive behaviours include: 37. In your opinion, what would the ideal home for this animal look like? Temperament and Personality 38. My herptile is used to: living with children visiting with children not used to children 39. These children are aged: 0-3 yrs 4-6 yrs 7-10 yrs 11-15 yrs 16 yrs+ 40. My herptile: enjoys being with children tolerates children is nervous of children is aggressive towards children 41. My herptile is used to living with: Adult female, Adult male, Female children, Male children 42. In your opinion, would this animal do well in a home with children? Why/why not? 43. My herptile is used to: living together with the same species living near same species has never had contact with the same species 44. My herptile is used to: living together with other herptile species: living near other herptile species: has never had contact with other herptile species 45. My herptile is used to: living with dogs breed(s)/age(s): living with cats age(s): living with other animal(s): 46. My herptile is nervous of: dogs cats other animal(s): 47. My herptile is aggressive with: dogs cats other animal(s): 48. In your opinion, would this animal do well in home with other species? Why/why not? (please specify species): 49. With strangers, my herptile is usually: calm nervous aggressive 50. In a new environment, my herptile is usually: calm/curious nervous/fearful 51. When traveling in the car, my pet is usually: calm/relaxed nervous/fearful
52. My herptile is afraid of: Handling 53. I can pick up my herptile: always sometimes never 54. When handling, my herptile: enjoys it seems indifferent struggles bites 55. My herptile is used to being soaked: regularly rarely never 56. The method I use to soak my herptile: 57. When soaking, my herptile: enjoys it seems indifferent struggles bites 58. My herptile is used to nail trims: regularly rarely never 59. Nail trims are done: at home at a groomer at the vet 60. When trimming nails, my herptile: enjoys it seems indifferent struggles bites Herptile s Health Record 61. Veterinary Clinic: 62. Veterinarian s Name: 63. Clinic Location: 64. Clinic Phone #: 65. How long have you used this clinic? 66. Has this herptile been to any other clinic? No Yes: 67. Do you have the Veterinary Health Records? Yes No Have been faxed 68. How does your herptile react to visiting the vet clinic? Well Poorly Nervous 69. How does your herptile react to the veterinarian? Well Poorly Nervous 70. Has your animal had any medical concerns in the past? No Yes If yes, please specify: 71. Does your animal have any current medical concerns? No Yes If yes, please specify: 72. Has the animal been on any medications (including homeopathic remedies) in the past? No Yes: 73. Is the animal currently on any medications (including homeopathic remedies)? No Yes: 74. Have there been any recent changes to the following:
skin/shell condition eye condition appetite energy level breathing basking water consumption other behaviour: 75. When was your herptile s last shed? 76. When was your herptile last at the vet? 77. What procedures were done? 78. Is there anything else you would like us to know about your herptile? In order to match your animal to an appropriate adopter, please provide as much information as possible: INTAKE NOTES
FACILITATED ADOPTION ANIMAL BEHAVIOUR SUMMARY Date: To be shared with adopters, please do not include personal information Pet s name: Does he/she respond to his/hers name: Yes No Diet 4. What kind of food do you feed your pet?: Only dry Only canned Mix of dry/canned Special diet Brand of food: Frequency and amount of food fed: 5. What else does your pet eat? (Table scraps, treats, etc.) Indoor/Outdoor Habits 6. My pet is used to living in a(n): Apartment/condo House with no/small yard House with large yard Farm or rural property 7. My pet is house or litter trained: Yes No Sometimes Comments: 8. On average, how many hours a day is your pet left alone?: 9. My pet gets walks a day; for minutes each time 10. When I m not home, my pet is kept: In a crate Isolated to a room/basement Loose in the house Outdoors Comments: 11. When it comes to furniture, my pet is: Allowed on all furniture Allowed on some furniture Not allowed on furniture Allowed on his/her own bed Comments: Training/Behaviour notes 12. My pet knows the following commands and has the following training:
13. Behaviour concerns Current behavior issues: How have you been dealing with these behavior issues so far?: Current behavior issues: How have you been dealing with these behavior issues so far?: 14. Is there anything other information about your pet that you feel is important for their adopters to know?