Ervets4pets.com - Avian Intake Form

Avian Medical History Form
Patient Name:*

First NameLast Name
Date*

MonthDayYear
Date
Owner Name:*
Presenting Complaint:
What is going on?*
When did it start?*
Have you noticed the following symptoms?*

Behavior changeVomiting/regurgitationLethargy/decreased activityChange in stoolsChange in appetiteNasal or ocular dischargeChange in urateWeight changeSneezingScratchingIncreasing breathing rate/effortFeather loss/abnormalitiesChange in vocalizationLameness
If your pet has had behavior changes, please describe (screaming, aggression, feather damage)*
Have there been any pets in contact with this one that have died within the last month?*

YesNo
If yes, explain:*
Has this pet been sick at any other time during the last 12 months?*

YesNo
Explain:*
If so, by whom was it seen?*
Has this pet been given any medications or supplements in the past 7 days?*

YesNo
If yes, which ones?*
Does this pet have any chronic medical conditions?*

YesNo
Please explain
Does this pet take any medications regularly?*

YesNo
If so, list medications and dosing
History
How long have you owned this pet?*
Where did you get your bird? (breeder, private, home, pet store, surrendered)*
If surrendered, why?
Has the bird been sexed?*

Blood Test (DNA)VisualSurgicalNo
Can your bird fly?*

YesNo
Was your bird hand fed?*
Was your bird domestically raised or imported?*
When was your bird’s last molt?*
Reproductive history:
Is your bird used for breeding?*

YesNo
If your bird is a female?*

YesNo
Have you seen any egg laying?*

YesNo
If so, how often?*
When was the last time she laid an egg?*
Has she ever been egg bound?*
Housing information:
Where is your bird kept and what percent of the time?*
When indoors, what percent of the time is spent in the cage?*
% Free*
In the House %*
Cage description (size, shape, bar spacing, perches, toys, etc.)*
Hours of light per day*
Is UVB light supplied?*
House temperature: Daytime*
Night time*
Cage lining*
Cleaning schedule/products *
Is this pet housed with another bird?*

YesNo
Are there any other birds in the house?*

YesNo
Where are they kept in relation to this bird?*
Is your other bird sick?*
Are there any other pets in the house?*

YesNo
If so, what kind?*
Have there been any changes in the household? (new people, new pets, remodeling, etc.)*
Does anyone smoke in the house?*
Are Teflon pans used for cooking in the house?*
Diet:
What percentage of food does your bird eat?
Pellets %*
Seed %*
Table Food %*
Types and Percentage of Table Food Your Bird Eats
Fruits %*
Vegetables %*
Other %*
What Brand of food do you feed?*
What treats are given?*
How often?*
Are there any recent diet changes?*

YesNo
Describe*
Do you give supplements?*

YesNo
If so, what kind?*
How is water offered? (bottle, bowl, cage cup)*
How often is water changed?*
How often are food dishes washed?*
What type of soap/disinfectant is used?*
Should be Empty:

Avian Medical History Form

Presenting Complaint:

History

Reproductive history:

Housing information:

Diet:

What percentage of food does your bird eat?

Types and Percentage of Table Food Your Bird Eats