Poultry History Questionnaire

Poultry History Questionnaire
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Booking an appointment for*

IndividualFlock (if you have 5 or more birds of the same species that are housed together.)
Individual
Pet Name
Species
Date of hatch or estimated age
Sex
How long have you had the bird
Where did you acquire the bird
Flock

Please fill out the information in this section if you have 5 or more birds of the same species that are housed together.
Species
Number of birds in flock
How many birds in the flock are sick or showing symptoms?
Age range of individuals:
Number of males / females
Flock purpose (meat, egg, pet)
Reason for consult*
Current symptoms*
Length of symptoms (# of days, weeks or months)*
Are symptoms improving, worsening or staying the same?*
How long have you had the bird(s)?*
Where did you acquire the bird(s)?*
Have there been any new additions in the last 90 days?
Have there been any recently deceased birds?
What are your quarantine procedures?
What do you feed your bird / flock?*
How is the bird / flock appetite and energy level?*
Are any supplements given?*
How is your bird / flock housed?*

IndoorOutdoorCageFree-roam
How often do you clean / sift your birds / flocks’ area?*
Is your bird / flock in contact with other animals or household pets?*

YesNo
If yes, what kind and how many?
How many hours of sleep does your bird / flock get at night?*
How many hours of sunlight is your bird / flock exposed to each day?*
If your bird / flock lays eggs, describe usual frequency and number of eggs laid
Do you have any behavioral concerns?*

YesNo
If yes, describe the behavior and tell us how long it has been going on.*
Is there any past medical history?*

YesNo
Any previous injuries or illness?*

YesNo
Is the bird / flock receiving any current medications?*
Does your bird / flock receive any regular treatments?*

WormingParasite treatmentsOther
Has your bird / flock received any vaccinations (including Marek’s vaccine for chickens)?*

YesNo
If Yes, list vaccines name and date received
Should be Empty:

Poultry History Questionnaire

Individual

Flock