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
SPECIES/BREED
GENDER
Sex testing by:
Please describe primary concern or the signs you have noticed.
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? - Yes/No | 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 approximate volume.
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?
Additional comments or questions:
Should be Empty:

CLIENT INFORMATION

PATIENT INFORMATION

DIET

ENVIRONMENT