Avian History Form

Please provide the information below as completely as possible. All information is strictly confidential. All fields with an asterisk (*) are required.

Patient Information

Owner's Name*
Pet's Name*
Species*
Age*
Sex*
Male
Female
Unknown
How was bird sexed?*
Blood Test (DNA)
Surgically (endoscopy)
Visually
Not Sexed
Color/Markings*
Specific Identification
Tattoo
Microchip
Leg Band
Other
Describe ID location and Details (if applicable)

Reasons for Today's Visit

What signs prompted today's visit?*
How long have you noticed the problem?*
How has the problem changed?*
Worse
Better
Same
Has anything seemed to make the problem worse or better?
Does the problem tend to happen at a certain time of day or time of year?
On a scale of 1 to 10, with 1 being normal and 10 being death, how would you rate your pet's problem?*
Have you noticed any of the following signs? (check all that apply)
Behavior change
Lethargy / change in exercise
Nose or eye discharge
Sneezing
Increased breathing rate or effort
Change in voice / vocalization
Vomiting / regurgitating
Change in stool quality
Change in urine / urate quality / color
Change in urine volume
Lameness / weakness
Change in thirst
Change in appetite
Change in weight
Scratching
Feather loss / abnormalities
Skin lumps (masses)
If your bird has been sick before, please describe.
If your bird has been seen by another veterinarian, who was that vet?
Please describe any medications your bird is currently taking.
Have you tried any over-the-counter remedies or supplements?
If any tests have been performed on your bird, please check those that apply.
Psittacosis (Chlamydophila)
CBC
Chemistry panel
Beak and Feather Disease
Polyoma Virus
Parasite examination
Radiographs (x-rays)

Please describe any other tests not listed above.
Has any member of your household (human or animal) had an illness in the past month?*
Yes
No

General History

How did you acquire this bird?*
Source:*
Private Breeder (describe)
Pet Store (describe)
Wild Caught (imported)
Unknown
Please provide any other details on the source.
Approximate date when acquired.*
Approximate age or size when acquired.*
Bird is a:*
Pet
Breeder
Other
If other, please describe
Has any reproductive behavior been noted?*
Yes
No
If so, please describe.
Please describe any past reproductive issues. Has your bird been "spayed" (undergone a salpingohysterectomy)?
When was the last molt?*
Is your bird vaccinated?*
Yes
No
If so, please list vaccines and dates.
Are your bird's wings trimmed?*
Yes
No
Do you have any other birds or other pets?*
Yes
No
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?*
Yes
No
How does your bird get excercise?*

Housing

Where is this bird kept (select all that apply)?*
Indoors
Outdoors
Cage
Aviary
Free in House
Is your bird allowed free in the house at any time?*
Yes
No
If yes, how frequently?
Is your bird supervised at all times when outside of cage?*
Yes
No
Is this bird housed alone?*
Yes
No
If no, describe cage mates.
Please describe type / size of cage.*
What cage furniture is present?*
Perches
Toys
Swings
Nestbox
Other
What is used for substrate on the bottom of the cage?*
Is a grate present on the bottom of the cage?*
Yes
No
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?*
Yes
No
If yes, please describe.
What is the nighttime procedure for your bird?*
Cage Covered
Placed in Nighttime Cage
No Change from Day
How many hours of undisturbed darkness does the bird have in each 24 hour period?*
Does the bird have any exposure to full spectrum (UV A or B) lighting?*
Yes
No
If yes, please describe.
Do any smokers live in the house or visit regularly?*
Yes
No
Are any of the following present in your home? (check all that apply)
Sprays (air fresheners, insecticides, cleaning products, etc.)
Candles
Fireplaces
Teflon cookware
Wood or oil burning heaters
Houseplants to which the bird has access
Painted or linoleum surfaces to which the bird has access
Dust (within the house or nearby construction)

Diet

How often is food offered to your bird?*
If pellets are given, what brand/type?
If seed mix is given, what brand / type?
Do you sprout any of the seeds before feeding them? If so, how?
What types of sprouts are offered/how frequently?
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?*
Yes
No
If yes, please describe.
Does your bird forage for any of his/her food?*
Yes
No
If so, what percentage of the food is offered through foraging?
Please describe the foraging opportunities offered.
How is water offered?*
Bowl
Sipper Bottle
Other
What is the source of your bird's water?*
Tap water
Bottled water
Well water
Rain water
How often is the water changed?*
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.
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