Ervets4pets.com - Poultry Intake Form

Poultry History Form
Patient/Owner Information
Patient name*
Date*

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

Behavior ChangeLethargy/ Drecreased ActivityChange in AppetiteChange in UrateSneezingIncreasing Breathing Rate/EffortWeaknessVomiting/RegurgitationChange in StoolsNasal or Ocular DischargeWeight ChangeScratchingFeather Loss/AbnormalitiesLamenessNoneOther
Has your pet exhibited any behavior changes (screaming, aggression, feather damage, etc.)*

YesNo
Please describe*
Have there been any pets in contact with this one that have died within the last month?*

YesNo
Please explain*
Has this bird been sick at any other time during the last 12 months?*

YesNo
Please explain and by whom was this pet seen*
Has this pet been given any medications or supplements in the past 7 days?*

YesNo
Please describe (type, frequency)*
Does this pet have any previous or chronic medical conditions?*

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

YesNo
Please list the medications and dosing schedule*
General information
How long have you owned this bird?*
Is this bird vaccinated?*
Where did you get your bird? (Breeder, Store, Home, Surrendered)*
Was your bird domestically raised or imported?*
Reproductive history
Is your bird used for breeding?*

YesNo
Is your bird a female?*

YesNoUnknown
Have you seen any egg laying?*

YesNo
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.)*
How often is your pet’s enclosure cleaned and with what products?*
How many birds are in the flock?*
Are all of the other birds vaccinated?*
Are any of the other birds sick?*
Have there been any new additions?*
Diet
What percentage of food does your bird eat?
Pellets %*
Table Food %*
Other %*
Types and percentage of table food your bird eats
Fruits %*
Vegetables %*
Other %*
What Brand of food do you feed?*
Are there any recent diet changes?

YesNo
Please describe
Do you give supplements? (Vitamin C, Calcium)*

YesNo
If so, what kind and how frequently?
How is water offered?*
How often is water changed?*
How often are food dishes washed?*
What type of soap/disinfectant is used?*
Additional Comments*
Should be Empty:

Poultry History Form

Patient/Owner Information

Presenting Complaint

General information

Reproductive history

Housing information

Diet

What percentage of food does your bird eat?

Types and percentage of table food your bird eats