Poultry History Form

Poultry History Form
Date

Month Day Year
Date
Name

First Name Last Name
Pet's Name:
Breed:
How long have you owned this bird?
Source of bird?
Bird is kept in:
Any other birds kept in the same cage, aviary or flock?

Yes No
If so, what kind and how long have they been together?
What is the bird used for (meat, eggs, etc.)?
How many laying boxes are in the coop and how big are they?
Birds laying history:
What kind of perches and how many are there in the coop?
What kind of substrate is used to line the bottom of the coop?
How frequently is the substrate changed?
How frequently is the entire cage/coop cleaned?
How often are the food and water dishes cleaned?
What type of diet (pellets/seed/fruits/vegetables/nuts/other) is fed and what brand?
Where do you buy the food that used?
How much do you feed?
How old is the feed?
Do you use vitamin/mineral supplements?

Yes No
If so, what type and how often?
Has the bird had any vaccines?

Yes No
Has your bird received any home treatment or veterinary care previously?

Yes No
If so, please explain. Include medication name, dosage and length of treatment.
Has your bird had labwork?

Yes No
If so, where was the labwork performed?
What is the primary reason for your bird's visit today and what concerns do you have?
Should be Empty: