Avian Medical History
Pre-Visit Form
Your Full Name
*
First Name
Last Name
What is the date of your appointment?
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Month
-
Day
Year
Date
Who is your pet's appointment with?
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Dr. Tom Frankmann
Dr. Jessica DeMarco
Dr. Carolyn Askew
Dr. Stephanie Secic
Veterinary Nurse
I am not sure
Your Pet's Name
*
Please confirm your email address
*
example@example.com
Cell Phone Number
*
-
Area Code
Phone Number
Husbandry:
What species / breed is your pet?
*
Where did you purchase / adopt your pet?
How old was your pet when you purchased / adopted?
Are you the pet's first owner?
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Yes
No
Do you have other pets in your home? If so, what type(s), are they caged, and do they have contact with this pet.
Where does you pet live?
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Indoor
Outdoor
Both indoor and outdoor
Describe cage; size, shape, material, floor (solid / wire), location?
If possible, please upload a photo of the habitat / enclosure.
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What type of bedding / substrate? Changed how often?
What type of room / window lighting? How many hours of light is pet exposed to in the room?
Heat gradient (hottest and coolest temps) in cage? Day vs. night? How is this monitored?
Typical temperature range of room in which cage is kept? Does this change seasonally?
How is water provided? Bowl, dripper bottle, changed how often, what type of water?
Cage furniture: perches (types,) bowls, hides, cuttlebone, toys, branches, hammocks, other? Cleaned when / how?
Diet: Amount / frequency / brand of seed, sprouted millet, pellets, vegetables, fruits, seeds, treats, other?
Any meat / animal products? Type, amount, frequency.
Medications / supplements: Brand, dose, frequency, last given?
Socialization / handling: Who cares for the pet? Favorite person? How much time out of cage on average, is this observed or unobserved? Grooming / play? Time outdoors, describe?
Is your bird flighted? Time out of cage, allowed to fly. Wings trimmed, by who, how often?
Medical History:
What brings you in today?
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Wellness visit
Medical visit
Symptoms: Onset, duration, severity, progression, other pets or people affected?
Has there been a change in the diet, cage, surroundings (home), cage mates, caretaker, or routine that may have caused the onset of symptoms?
Possible trauma, toxin, ingestion of atypical food, exposure to smoke / fumes / chemicals?
Changes in appetite, drinking, urination, feces / droppings? Describe:
Any measured or suspected weight gain / loss?
Changes in: activity level or behavior / routines? Describe:
Changes in respiratory rate, effort, or sound?
Changes in coat? Lesions, feather loss, itching?
Changes in mobility, limping, suspected pain when handled? Describe:
Has your pet laid eggs? How many eggs / how often? Any difficulty?
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