Avian Medical History

YOUR BIRDS MEDICAL HISTORY
This is my current contact informationMy contact information has changed. Please see receptionist with any changes
Date

MonthDayYear
Date
Owner last name:

First NameLast Name
Bird's name:

First NameLast Name
Has your bird been sexed?

YesNo
Method of sexing:
Does your bird have a microchip?

YesNo
Describe why you brought your bird to see us today:
Please select any current symptoms:

Vomitingabnormal droppingsabnormal activityincreased drinkingcoughinglabored breathingweight losschange in appetiteblood in cageblood in droppingslamenessdropped wingswelling or lumpspaindifficulty perchingdifficulty flyingruffled appearancetail bobbingdirty bottomseizuresfeather lossitchingsneezingeye dischargenasal discargeOther
Has your bird had any precious illnesses or treatments?
Previous Veterinarian:
Have you requested records to be sent to us?

YesNo
Is your bird vaccinated?

YesNo
For what diseases?
Where did you obtain this bird?
How long have you owned this bird?
Describe anything you know about your bird's life before living with you:
List any other birds in the house:
How does your bird entertain itself?
Select all that characterize your bird's personality:

RelaxedAnxiousPlayfulFearfulAggressive
Describe the diet that is offered: list brand names, quantities, proportions, and contents. What is eaten? What is found onthe bottom of the cage? Have appetite or dietary preferences changed?
List any supplements provided (e.g. vitamin/mineral powders/liquids, cuttlebone, grit).
Describe caging and perches in terms of sizes, construction materials, and location.
How often do you clean the cage, and cleaning products used
Do you allow this bird to fly?
Describe toys: how many, construction materials, destructibility, and rotation schedule.
List any other items in cages or on/around perches.
Describe bathing routine: how often, what is used, how does the bird respond?
Where does the bird sleep? How many uninterrupted dark/quiet hours per night?
Describe lighting in terms of intensity, source, and hours per day. Is the bird exposed to natural sunlight that has not been filtered through glass or plastic? If so, how often and for how long?
Any possible exposure to hazards including: metals, insecticides, plants, vapors, exhaust fumes, aerosolized particles, contaminants on handler’s skin or clothing (e.g. cigarette smoke residue, perfume, or cosmetics), garden chemicals, cleaners, bathing sprays, cooking vapors, contact irritants, potential allergens?
Bird’s Behavior
Screaming?

YesNo
Biting?

YesNo
Is bird kept flighted?

YesNo
Egg laying/hormonal behaviors/regurgitation?

YesNo
Bonded to one person?

YesNo
Does bird forage for food or treats?

YesNo
Does bird play with toys?

YesNo
Feather chewing or plucking?

YesNo
Mutilation of skin/feet?

YesNo
STATEMENT OF FINANCIAL RESPONSIBILITY

I am aware that I am responsible for all charges related to medical services that my pet receives at Brook-Falls Veterinary Hospital & Exotic Care. I understand that I will be asked to leave a deposit for medical services should my pet require a hospital stay. I understand that I must pay in full at the time medical services are completed. I have been advised that any charges revealed during post care audits will be invoiced in a timely manner and remain my financial responsibility.
Signature

Clear
Date

MonthDayYear
Date
FEATHER PICKING HISTORY
PLEASE COMPLETE THIS SECTION ONLY IF YOU BIRD HAS FEATHER LOSS OR MUTILATION

CompleteSkip
What date did the feather picking or self-mutilation begin?
Has the bird picked feathers in the past, stopped, and then resumed picking?

YesNo
Was it seasonal? If so what season?
Did the feathers return? If so did they appear normal?
Was it associated with any other behaviors? i.e. mating or nesting?
Does the bird also groom itself normally? If so, describe grooming in terms of frequency and duration.
Does the bird pick when alone and no human is present?
Does the bird pick when you or others are present?

YesNo
Is it most commonly associated with a certain person?
Describe bird’s behavior while plucking.
How do you or others respond?
What does the bird do with the feathers?
Does your bird seem itchy?
Does your bird scream or vocalize when picking?
Will your bird interrupt an activity (i.e. eating) to pick?
Does the picking correspond to a certain time of day?
Should be Empty:

YOUR BIRDS MEDICAL HISTORY