Poultry History Form

Date

Name

First NameLast Name

Pet's Name:

Species and breed (if known):

What is the primary reason for your visit and what concerns do you have today?

Has your pet received any treatment at home? What was given, and how long was it given?

Has your pet been seen at another clinic? If so, please list the clinic name so we can call for records.

The following questions are regarding the husbandry, or at home living environment for your pet. This information helps us get a full picture of what may be going on with your pet.

How old is your pet?

How long have you had your pet?

Where did you get your pet from?

What is your pet housed in (i.e. free-roam in house, outdoor coop, free-range, etc.)?

Please email or upload pictures of your enclosure.

Browse Files

What is the size of your pet’s enclosure (L x H x W)?

How much time does your pet spend outside of the enclosure?

How many other birds are in the same enclosure or flock?

What is the bird used for (i.e. meat, eggs, pet)?

What substrate (bedding) do you use in the enclosure?

How frequently do you spot clean and fully clean the enclosure?

How often do you clean the food and water dishes?

What do you use to clean the enclosure and dishes?

How many laying boxes are in the coop? How big are the boxes?

When is the last time pet has laid?

What do you primarily feed your pet (i.e. pellets,seeds, fruits/veggies)? Please list brands if known.

How much and how often do you feed your pet?

What treats do you give your pet? How often?

Do you use vitamin or mineral supplements? If so what kind and how often?

What is the maximum and minimum temperature in the enclosure?

What heating source is available for the birds in the wintertime? Do you use a de-icer for the water dish?

Have there been any new birds recently introduced to the flock?

How often does this pet interact with the other pets?