Avian Health Questionnaire
Date
-
Month
-
Day
Year
Date
Owner’s Name
Pronouns (optional)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (home)
Please enter a valid phone number.
Phone (cell)
Please enter a valid phone number.
Phone (work)
Please enter a valid phone number.
Email
example@example.com
Emergency Contact (other than immediate family)
Phone Number
Please enter a valid phone number.
Pet’s Name
Species
Colour
Age or Hatch Date
Gender:
Male
Female
Unknown
Gender determined by:
DNA (feather/blood)
Endoscopy
Other
Permanent Identification:
Band #:
Microchip #:
Date Acquired:
-
Month
-
Day
Year
Date
Source:
Pet Store
Breeder
Private
Rescue
Wild-caught
Other:
Was your bird quarantined when acquired?
Yes
No
If yes, give details:
Has your bird been tested for any of the following:
Chlamydia
Fecal Test
Beak & Feather Disease
Polyoma Virus
Blood test (type):
Do you have other birds or pets?
Yes
No
If yes, give details:
Have you or your bird had any contact with other birds in the last 30 days?
Yes
No
If yes, give details:
When was the last bird added to your collection?
Housing & Environment:
Where in the house does your bird live?
Describe their enclosure, or living space (dimensions, type, objects – eg, nest box, perches, swings, ladders, toys):
What is used to line the bottom of the enclosure?
How often is their enclosure cleaned?
What cleaning/disinfectant agents are used?
How much time does your bird spend out of their enclosure?
Are they supervised when out of their enclosure?
Yes
No
Are bathing/spraying facilities provided?
Yes
No
If yes, give details:
Is your bird exposed to full spectrum (UVA, UVB) sunlight or lighting?
Yes
No
If yes, give details including brand:
What is your birds light/dark cycle?
Is your bird exposed to any of the following:
Smoke
Aerosolized products
Non-stick cookware
Diet:
How often do you feed your bird?
What foraging opportunities do you provide for your bird during mealtimes?
Indicate which foods are eaten and in what amounts (include brand/type):
Yes/ No
Amount
Brand
Type
Pellets:
Yes
No
Seed mixtures:
Yes
No
Fresh fruits/vegetables:
Yes
No
Meat:
Yes
No
Treats:
Yes
No
Other:
Do you give your bird any nutritional supplements (eg, vitamins, calcium, etc)?
Yes
No
If yes, give details:
How is water provided?
Bowl
Bottle/tube
Dripper/spray
Other
Health & Fitness:
Are your birds wings trimmed?
Yes
No
When was their last molt?
Does your bird have a reproductive history?
Yes
No
If yes, give details:
Do you have any of the following concerns (check all that apply):
Fluffed feathers
Sleeping more
Behavior change
Change in vocalization
Appetite change
Change in droppings
Vomiting
Constipation
Tail bobbing
Breathing difficulty
Trouble perching
Collapse/fainting
Feather loss/plucking
Bleeding
Trauma (bitten, injured, etc.)
Drooping/injured wings
Lameness
Eye/nose/ear discharge or injury
Excessive drinking
Blindness
Other
Is your bird currently on any medications?
Yes
No
If yes, give details:
Do you have any specific questions or concerns?
Submit
Should be Empty: