Avian History Form
An accurate history of your pet and their environment is extremely important. We would appreciate your cooperation in providing us with the following information. Please check the appropriate boxes or use the spaces provided.
Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Email:
example@example.com
Date:
*
/
Month
/
Day
Year
Today's Date
PATIENT INFORMATION
Patient Name:
*
Species & Breed:
*
Gender:
*
Male
Female
Unknown
If gender is known, how was it determined?
*
If the gender is unknown, please type "N/A".
Date of hatch or estimated age?
*
Wild caught or hand raised?
*
Date acquired?
*
Use an approximation if you do not know the exact date.
Source?
*
Example: Pet Store, Breeder, Exotic Show, etc.
Female Questions
If your pet is a female, answer the following questions additionally. If your pet is a male, you may skip to the 'ENVIRONMENT' section.
Have you ever bred or do you plan to breed this bird?
Yes
No
Unsure
How many clutches of eggs has your bird laid?
When was the most recent egg?
/
Month
/
Day
Year
Date
Was the egg normal?
Yes
No
If no, what was abnormal?
Any reproductive problems with this bird or any problems with her offspring? If yes, please describe.
ENVIRONMENT
What room in the house is your bird kept in?
*
Are there any other birds/pets in the household? If yes, what type?
*
Describe the cage:
*
Type, size, perches, toys, etc.
What is on the bottom of the cage?
*
Do you regulate the temperature of the room that your bird is kept in?
*
Yes
No
If so, how and at what temperature range?
*
How much time does your bird spend outside of their cage?
*
Is your bird supervised when our of the cage?
*
At all times
Sometimes
No
My pet does not leave its cage
Are there any recent changes to your bird's environment? If yes, please describe.
*
EXPOSURE HISTORY
Has your bird been exposed to any birds other than your own?
*
Yes
No
If yes, when and where
*
If no, please type "N/A"
Has your bird had any exposure to the following:
*
Cigarette Smoke
Kitchen Fumes
Non-stick Cookware
Chewing on Houseplants
Chewing on Walls/Furniture
Unusual amount of dust or nearby construction
None
Do you have air filtration?
*
Yes
No
Please list any air fresheners, cleaning products, or insecticides that are used in the same room as your bird:
*
If none, please type "N/A".
Please list other possible toxins or irritants:
*
If none, please type "N/A".
DIET AND MEDICATION
For this bird, please list the amount fed/given and at what frequency of BIRD PELLETS:
*
Include brand, if known. If your pet does not get BIRD PELLETS, please type "N/A".
For this bird, please list the amount fed/given and at what frequency of SEED MIXTURE:
*
Include brand, if known. If your pet does not get SEED MIXTURE, please type "N/A".
For this bird, please list the amount fed/given and at what frequency of TABLE FOOD:
*
Include what types. If your pet does not get TABLE FOOD, please type "N/A"
If your pet is given OTHER, please describe and list the amount fed/given and what frequency:
*
If this does not apply, please type "N/A".
How often is your bird's food changed?
*
How is water supplied to your bird?
*
What TREATS does your bird get?
*
Please include types and frequency of the TREATS given.
What types of SUPPLEMENTS do you give your bird?
*
Include vitamins, minerals, grit etc. with types and frequency. If your bird does not get SUPPLEMENTS, please type "N/A".
Any recent additions or changes to diet or medications? If yes, please describe.
*
We pledge to do our very best care for your pet's health needs. In return we ask you to accept the responsibility for charges incurred in the treatment of your pet. Payment is required at the time services are rendered. We accept major credit cards, cash, checks, and CareCredit. We may also require deposits for certain services. For exotics, a deposit is taken at the time of scheduling the exam. By signing this form, you agree to pay for all charges incurred in the care of this pet.
*
Date
*
/
Month
/
Day
Year
Date of Signature
Submit
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