Happy Tails - Avian History Form

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A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about you can discuss it in more depth with the veterinary staff during your appointment.
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Email* This field is required.
example@example.com
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ANIMAL DETAILS* This field is required.
Avian name or identification
Common or scientific species name
Date of birth
Age
Please Select
Please Select
Male
Female
Male Neutered
Female Spayed
Unknown
Sex
Please Select
Please Select
Captive bred
Wild caught import
Unknown
Origin
Please Select
Please Select
DNA
Endoscopy
Visual
Other
Determined by
4
If Determined by Other, Please Specify
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How long have you had this bird?
From where did you obtain this bird?
Please Select
Please Select
Yes
No
Does this bird have a reproductive history?
6
Please give details
7
When did your bird last molt?
How often has your bird been molting?
Please Select
Please Select
Yes
No
Is your bird vaccinated?
8
Please give details
9
Does your bird get wing trimmed?
Yes
No
10
If yes, please give details
11
Do you have other birds or pets?
Yes
No
12
If yes, please give details
13
Have you or your bird had any contact with other birds in the last 30 days
Yes
No
14
If yes, please give details
15
When was the last bird added to your collection?
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What is the primary complaint or what signs have you noticed? How long have these problems been present?
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What health problems has your bird had previously?
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Has your bird received any treatment in the last 30 days?
Yes
No
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If yes, please give details (what was used, dosage, how often, duration)
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Have you noticed any change in your bird’s behavior?
Yes
No
21
If yes, please give details
22
Have any other animals or persons in the household had any illness in the last 30 days?
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How often do you feed your animal?
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Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):
Seed mixtures: Brand?    Brand Name     Amount?    Amount Served
Pellets: Brand?    Brand Name     Amount?    Amount Served
Fruits and/or vegetables: Type?    Fruit or vegetables    Amount?    Amount Served
Meat (type and amount):  Type?    Amount?    Amount Served
Treats: Brand?    Brand Name    Amount?    Amount Served
Other:     If Other please specify
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Do you use any nutritional supplements?
Yes
No
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If yes what, how much, and how often
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Please Select
Please Select
Tap water
Bottled water
Rain/river water
What water supply do you provide
Please Select
Please Select
Bowl
Dripper system
Spray
How is water provided?
How often
How often is the water changed?
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Do you use any water supplements?
Yes
No
29
Please give details
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Have you noticed any changes in feeding or drinking behavior?
Yes
No
31
Please give details
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Have you noticed any changes in droppings (fecal material, urine and urates)?
Yes
No
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Please give details
34
Please Select
Please Select
Inside
Outside
Where is the cage located?
Please give details
What is the cage made of?
Cage size
What kind of bedding is used?
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What décor and furnishings are present?
Nest Box
Perches
Swings
Toys
Other
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If Other, Please Specify
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Please give details about décor and furnishings present
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Are bathing/spraying facilities provided?
Yes
No
39
Please give details
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How often is the cage cleaned?
What cleaning/disinfectant agents are used?
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What percentage of time does your bird spend inside and outside of its cage?
Inside %
Outside %
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Is the animal supervised when out of the cage?
Yes
No
43
Please give details
44
Does your bird have regular exposure to sunlight?
Yes
No
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Frequency and length of time
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Is your bird exposed to full spectrum (UVA and UVB) lighting?
Yes
No
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Brand?
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What is your bird’s light/dark cycle?
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Does anyone in the household smoke?
Yes
No
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Do you use any aerosolized products?
Yes
No
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Have there been changes in the bird’s environment in the last 3 months?
Yes
No
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Please give details
Should be Empty: