Avian Patient History
Name
*
First Name
Last Name
Pet Name
*
Date
*
-
Month
-
Day
Year
Date
Species / Breed
*
Color
*
Age / DOB
*
Actual or Estimate
Sex
*
Female
Male
Unknown
How long have you owned your bird?
*
Where did you acquire your bird?
*
Any previous health concerns?
Any history of egg laying?
When was the last clutch?
Any problems with egg laying?
Does your bird have a microchip?
*
Yes
No
Unknown
How often does your bird molt?
When was the last molt?
-
Month
-
Day
Year
Date
Was it normal?
Yes
No
Do you get your birds wings trimmed?
*
Yes
No
By whom?
When was the last trim?
-
Month
-
Day
Year
Date
Is your bird having normal droppings?
*
Yes
No
If no, please describe
Have you or your bird been in contact with any other pets within 30 days?
Yes
No
What type of cage is your bird housed in?
How long does your bird spend in cage?
How long does your bird spend outside of cage?
Where is the cage located?
Does your bird have free access to home?
Yes, supervised
Yes, unsupervised
No
Any outdoor time at an aviary?
Yes, supervised
Yes, unsupervised
No
How often is cage changed / cleaned?
*
Daily
Weekly
Monthly
What type of cleaning chemical is used?
*
What type of toys/furnishings are in the cage?
What do you feed your bird? Check all that apply
*
Pellets
Seeds
Table Food
Types and percentages of each
Pellets
Seeds
Table Food
Fruits
Vegetables
Other
What brand of food do you feed?
Of all the food you offer, what does your bird consume?
Does your bird receive any supplements?
*
Yes
No
Type of Supplements?
What type of water does your bird receive?
*
Tap
Purified
Sipper Bottle
Bowl
Do you use Spray or Mist?
Yes
No
Do you use any water supplement?
Yes
No
Type of Supplement?
How often is food or water changed?
How often are the food dishes washed?
What type of soap/disinfectant is used?
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