Poultry History Form
Patient/Owner Information
Patient name
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Date
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Month
-
Day
Year
Date
Owner name
*
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
Lethargy/ Drecreased Activity
Change in Appetite
Change in Urate
Sneezing
Increasing Breathing Rate/Effort
Weakness
Vomiting/Regurgitation
Change in Stools
Nasal or Ocular Discharge
Weight Change
Scratching
Feather Loss/Abnormalities
Lameness
None
Other
Has your pet exhibited any behavior changes (screaming, aggression, feather damage, etc.)
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Yes
No
Please describe
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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
Please explain
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Has this bird been sick at any other time during the last 12 months?
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Yes
No
Please explain and by whom was this pet 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
Please describe (type, frequency)
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Does this pet have any previous or chronic medical conditions?
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Yes
No
Please describe
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Does this pet take any medications regularly?
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Yes
No
Please list the medications and dosing schedule
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General information
How long have you owned this bird?
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Is this bird vaccinated?
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Where did you get your bird? (Breeder, Store, Home, Surrendered)
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Was your bird domestically raised or imported?
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Reproductive history
Is your bird used for breeding?
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Yes
No
Is your bird a female?
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Yes
No
Unknown
Have you seen any egg laying?
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Yes
No
If so, how often?
Housing information
Describe the Enclosure (Coop Size, Ranging Enclosure and Size, Free Range, Etc. )
What Type of Bedding is Used (Pine Shavings, Etc.)
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How often is your pet’s enclosure cleaned and with what products?
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How many birds are in the flock?
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Are all of the other birds vaccinated?
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Are any of the other birds sick?
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Have there been any new additions?
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Diet
What percentage of food does your bird eat?
Pellets %
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Table Food %
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Other %
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Types and percentage of table food your bird eats
Fruits %
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Vegetables %
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Other %
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What Brand of food do you feed?
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Are there any recent diet changes?
Yes
No
Please describe
Do you give supplements? (Vitamin C, Calcium)
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Yes
No
If so, what kind and how frequently?
How is water offered?
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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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Additional Comments
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Submit
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