AVIAN HISTORY FORM

AVIAN HISTORY FORM

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.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
ANIMAL DETAILS
Avian Name or Identification:*
Common or Scientific Name:*
Date of Birth*
Sex*

MaleFemale
Fixed*

NeuteredSpayedUnknown
Determined By*

DNAEndoscopyVisualOther
If Other, Please Explain:
Origin*

Captive BredWild CaughtImportUnknown
How Long Have You Had This Bird?*
From Where Did You Obtain This Bird?*
Does This Bird Have A Reproductive History*

YesNo
Please Give Details:
When Did Your Bird Last Molt?*
How Often Has Your Bird Been Molting?*
Is Your Bird Vaccinated?*

YesNo
Please Give Details:
Does Your Bird Get Wing Trimmed?*

YesNo
Please Give Details:
Do You Have Other Birds Or Pets?*

YesNo
Please Give Details:
Have You Or Your Bird Had Any Contact With Other Birds In The Last 30 Days?*

YesNo
Please Give Details:
When Was The Last Bird Added To Your Collection?*
REASON FOR PRESENTATION TODAY
What Is The Primary Complaint Or What Signs Have You Noticed?*
How Long Have These Problems Been Present?*
What Health Problems Has Your Bird Had Previously?*
Has Your Bird Received Any Treatment In The Last 30 Days?*

YesNo
If Yes, Please Give Details (What Was Used, Dosage, How Often, Duration)
Have You Noticed Any Change In Your Bird's Behavior?*

YesNo
If Yes, Please Give Details
Have Any Other Animals Or Persons In The Household Had Any Illness In There Last 30 Days?*

YesNo
DIET
How Often Do You Feed Your Animal?*
Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):
Seed Mixtures: blanks* . Brand: blanks*. Amount: blank*.
Pellets: blanks* . Brand: blanks*. Amount: blank*.
Fruits and/or Vegetable: blanks* . Type: blanks*. Amount: blank*.
Meat (Type & Amount): (Freshly Killed, Frozen/Thawed, OR Live POrey0 blanks* . Amount: blank*.
Treats: blanks* . Brand: blanks*. Amount: blank*.
Other Foods:
What Water Supply Do You Provide?*

Tap WaterBottled WaterRain/River Water
How Is The Water Provided?*

BowlDripper SystemSpray
How Often?*
How Often Is The Water Changed?*
Do You Use Water Supplements?*

YesNo
Please Give Details:*
Have You Noticed Any Changes In Feeding Or Drinking Behavior?*

YesNo
Please Give Details:*
Have You Noticed Any Changes In Droppings (Fecal Material, Urine and Urates)?*

YesNo
Please Give Details:*
Do You Use Any Nutritional Supplements?*

YesNo
If Yes, What How Much, & How Often?
CAGE ENVIRONMENT
Cage Size:*
Where Is The Cage Located?*

InsideOutside
Please Give Details:*
What Is The Cage Made Of?*
What Decor & Furnishings Are Present?*

Nest BoxPerchesSwingsToysOther
Please Give Details:*
Are Bathing/Spraying Facilities Provided?*
How Often Is The Cage Cleaned?*
What Cleaning/Disinfectant Agents Are Used?*
Please Give Details:*
What Percentage Of Time Does Your Bird Spend Inside & Outside Of Its Cage?*
Is The Animal Supervised When Out Of The Cage?*

YesNo
Please Give Details:*
Does Your Bird Have Regular Exposure To Sunlight?*

YesNo
Frequency & Length Of Time?*
Is Your Bird Exposed To Full Spectrum (UVA & UVB)?*

YesNo
Brand?*
What Is Your Bird's Light/Dark Cycle?*
Does Anyone In The Household Smoke?*

YesNo
Do You Use Any Aerosolized Products?*

YesNo
Do You Use Teflon Pans?*

YesNo
Do You Use A Self-Cleaning Oven?*

YesNo
Last Self-Clean Cycle?*
Have There Been Changes In The Bird's Environment In The Last 3 Months?*

YesNo
Please Give Details:*
Should be Empty:

AVIAN HISTORY FORM

ANIMAL DETAILS

REASON FOR PRESENTATION TODAY

DIET

CAGE ENVIRONMENT