Reasons for Today's Visit
What signs prompted today's visit?*
How has the problem changed?*
If your bird has been sick before, please describe.
Please describe any medications your bird is currently taking.
Please describe any other tests not listed above.
Has any member of your household (human or animal) had an illness in the past month?*
Please provide any other details on the source.
Has any reproductive behavior been noted?*
Please describe any past reproductive issues. Has your bird been "spayed" (undergone a salpingohysterectomy)?
Is your bird vaccinated?*
If so, please list vaccines and dates.
Are your bird's wings trimmed?*
Do you have any other birds or other pets?*
If yes, please list other pets and whether they have contact with this bird.
Has there been any contact between humans or birds in your household with any other birds in the last 3 months?*
How does your bird get excercise?*
Where is this bird kept (select all that apply)?*
Is your bird allowed free in the house at any time?*
Is your bird supervised at all times when outside of cage?*
Is this bird housed alone?*
If no, describe cage mates.
Please describe type / size of cage.*
What cage furniture is present?*
Is a grate present on the bottom of the cage?*
How often is the cage cleaned, using what method / products?*
How often are the food / water dishes cleaned, using what method / products?*
Describe any bathing / shower activity including how often.*
Has this bird's environment changed recently?*
What is the nighttime procedure for your bird?*
Does the bird have any exposure to full spectrum (UV A or B) lighting?*
Do any smokers live in the house or visit regularly?*
If vegetables are given, what types and are they frozen, fresh, dehydrated, or in some other form?
If fruits are given, what types and are they frozen, fresh, dehydrated, or in some other form?
If proteins are offered, what sources (tofu, egg, meat, cheese)?
If treats are offered, what types?
What is the predominant diet of your bird; i.e., of the foods that are offered, what does your bird actually eat?*
What supplements, if any, are offered? How often?
Any recent diet changes?*
Does your bird forage for any of his/her food?*
Please describe the foraging opportunities offered.
What is the source of your bird's water?*
Thank you for taking the time to fill out this form. This information will assist your veterinarian in providing the best possible care for your bird.