Date
/
Month
/
Day
Year
Date
Appt. Time
Bird's Name
Species
Age
Pet Bird/Breeder
Background Information:
Length of time owned
Where acquired?
Breeder?
Pet Store
Other
Vaccination History
When was last molt?
Character of feces
How Often is your bird handled?
Daily
Occasionally
Never
Husbandry
Housed Indoors/Outdoors?
Is your bird ever taken outside?
Yes
No
Where is cage located?
Type of Caging
Size of Caging
Cage Substrate?
How often is cage cleaned?
Type a question
Yes
No
What type of disinfectant is used when cleaning cage?
Types of toys/perches offered?
Nutrition:
Type of Food Offered
Pellets?
Yes
No
If yes, What Brand?
Amount fed/frequency
Seed?
Yes
No
If yes, What Brand?
Amount fed/frequency
Fruit?
Yes
No
If yes, What type?
Amount fed/frequency
Vegetables?
Yes
No
If yes, What type?
yes, what types?
Amount fed/frequency
Types of Supplements/Treats offered
Water Source
How often is water changed?
Any other birds?
Yes
No
If yes, specify?
Any other pets?
Yes
No
If yes, specify?
Birds are housed together or singly?
If not housed together, where are other birds located?
Any new additions to the bird population?
Yes
No
If yes, specify?
Were the new additions properly quarantined separate from rest of bird population?
Past Medical History/Problems:
Current Presenting Problems:
Duration of Problem:
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