Avian Medical History Form
Patient Name:
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First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Owner Name:
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Presenting Complaint:
What is going on?
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When did it start?
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Have you noticed the following symptoms?
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Behavior change
Vomiting/regurgitation
Lethargy/decreased activity
Change in stools
Change in appetite
Nasal or ocular discharge
Change in urate
Weight change
Sneezing
Scratching
Increasing breathing rate/effort
Feather loss/abnormalities
Change in vocalization
Lameness
If your pet has had behavior changes, please describe (screaming, aggression, feather damage)
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Have there been any pets in contact with this one that have died within the last month?
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Yes
No
If yes, explain:
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Has this pet been sick at any other time during the last 12 months?
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Yes
No
Explain:
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If so, by whom was it seen?
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Has this pet been given any medications or supplements in the past 7 days?
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Yes
No
If yes, which ones?
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Does this pet have any chronic medical conditions?
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Yes
No
Please explain
Does this pet take any medications regularly?
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Yes
No
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)
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If surrendered, why?
Has the bird been sexed?
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Blood Test (DNA)
Visual
Surgical
No
Can your bird fly?
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Yes
No
Was your bird hand fed?
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Was your bird domestically raised or imported?
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When was your bird’s last molt?
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Reproductive history:
Is your bird used for breeding?
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Yes
No
If your bird is a female?
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Yes
No
Have you seen any egg laying?
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Yes
No
If so, how often?
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When was the last time she laid an egg?
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Has she ever been egg bound?
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Housing information:
Where is your bird kept and what percent of the time?
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When indoors, what percent of the time is spent in the cage?
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% Free
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In the House %
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Cage description (size, shape, bar spacing, perches, toys, etc.)
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Hours of light per day
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Is UVB light supplied?
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House temperature: Daytime
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Night time
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Cage lining
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Cleaning schedule/products
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Is this pet housed with another bird?
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Yes
No
Are there any other birds in the house?
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Yes
No
Where are they kept in relation to this bird?
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Is your other bird sick?
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Are there any other pets in the house?
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Yes
No
If so, what kind?
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Have there been any changes in the household? (new people, new pets, remodeling, etc.)
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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 %
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Seed %
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Table Food %
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Types and Percentage of Table Food Your Bird Eats
Fruits %
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Vegetables %
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Other %
*
What Brand of food do you feed?
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What treats are given?
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How often?
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Are there any recent diet changes?
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Yes
No
Describe
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Do you give supplements?
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Yes
No
If so, what kind?
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How is water offered? (bottle, bowl, cage cup)
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How often is water changed?
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How often are food dishes washed?
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What type of soap/disinfectant is used?
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Submit
Should be Empty: