Delton VH -Bird Lifestyle Questionnaire

Bird Lifestyle Questionnaire

Instructions: This form helps us get to know your bird so that we can provide the best level of care. If you have any questions, please don't hesitate to give us a call at 780.475.9225.
DATE

Month Day Year
Date
CLIENT INFORMATION
OWNER'S NAME *

First Name Last Name
CO-OWNER'S NAME *

First Name Last Name
ADDRESS *

Street Address

Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER *

Area Code Phone Number
SECONDARY PHONE NUMBER *

Area Code Phone Number
EMAIL *
example@example.com
PATIENT INFORMATION
PET NAME *
AGE/D.O.B *
When did you acquire this bird? *
SPECIES/BREED *
GENDER *
Sex testing by: *
If female, does she lay eggs? *

Yes No Not female
How often does she lay eggs? *
How many eggs per clutch? *
What time of year? *
Any live chicks in the past? *
Reason for Visit
Why did you make an appointment for your bird? *
Please describe the illness or symptoms in detail *
Please review all symptoms and select all that apply: *

Pet's activity level is normal Pet's activity level is decreased Pet's activity level is increased Pet's appetite is normal Pet's appetite is decreased Pet's appetite is increased Weight loss Weight gain Discharge from eyes and/or nose A change in droppings Increased thirst Decreased thirst Weakness
How long have these problems been present? *
What health problems has your bird had previously? (if any) *
Any changes in eating or drinking? - Yes/No *
Have you noticed any changes in droppings (fecal material, urine and urates)? - Yes/No | If yes, please describe. *
Has your bird received any treatment in the last 30 days? If yes, please give details (what was used, dosage, how often, duration): *
DIET

This section is VERY important. Be as accurate as possible. Indicate which foods are eaten and in what amounts (by number, weight, or percentage of the total amount eaten).
PELLETS | Brand and amount: *
SEED MIXTURES | Brand and amount: *
FRUITS and/or VEGETABLES | Type and amount: *
TREATS | Brand and amount: *
Other:
Do you use any nutritional supplements? Yes/No. If yes, what, how much and how often? *
ENVIRONMENT
What percentage of time does your bird spend INSIDE of its cage? *
What percentage of time does your bird spend OUTSIDE of its cage? *
What is your bird's light/dark cycle? *
This is the amount of hours in the dark and in light, either artificially (lights out and in a dark cage or room, or following natural light cycles.)
Additional comments or questions:
Should be Empty:

CLIENT INFORMATION

PATIENT INFORMATION

Reason for Visit

DIET

ENVIRONMENT