Avian Patient History Form Avian Patient History Form Owner Information Owner Name * Owner Name First First Last Last Email * Best Phone Number to Reach You * Secondary Phone Number How would you like us to contact you? * Phone Call Text Message Email Pet Information Avian Name or Identification * Common or scientific species name * Date of Birth * Sex * Male Female Unknown Sex determined by * DNA Endoscopy Visual Other Unknown Origin * Captive Bred Wild Caught Unknown From where did you obtain this bird? Does the bird have a reproductive history? * Yes No Unknown Please give details * When did your bird last molt? How often has your bird been molting? Is your bird vaccinated? * Yes No Unknown Please give details * Does your bird get wings trimmed? * Yes No Unknown Please give details * Do you have other birds or pets? * Yes No Please give details * When was the last bird added to your collection? Have you or your bird had any contact with other birds in the past 30 days? * Yes No Unknown Please give details * What is the primary complaint or what signs have you noticed? How long have these problems been present? What problems has your bird had previously? * Has your bird received any treatment in the last 30 days? * Yes No Unknown Please give details (what was used, dosage, how often, duration) * Have you noticed a change in your bird's behavior? * Yes No Unknown Please give details * Have any other animals or persons in the household had any illness in the last 30 days? * Yes No Unknown Please give details * Diet Information How often do you feed your animal? * Which foods are eaten? Seed mixtures, fruits, vegetables, meat, insects, treats, other? Please be specific with brand, type, and in what amounts (by number, weight, or approx. volume). If meat, please indicate if freshly killed, frozen/thawed, or live prey * Do you use any nutritional supplements? * Yes No Unknown Please indicate what, how much, and how often * What water supply do you provide? * Tap Water Bottled Water Rain/River Water How is the water provided (bowl, dripper system, tray) and how often? * How often is the water changed? * Do you use any water supplements? * Yes No Unknown Please give details * Have you noticed any changes in feeding or drinking behavior? * Yes No Unknown Please give details * Have you noticed any changes in droppings (fecal material, urine and urates)? * Yes No Unknown Please give details * Environment Information Where is the cage located? Inside or outside? Please give details * What is the cage made of? * Cage size? * What kind of bedding is used? * What decor and furnishings are present (nest box, perches, swings, toys, other)? Please give details * Are bathing/spraying facilities provided? * Yes No Unknown Please give details * How often is the cage cleaned? What cleaning/disinfectant agents are used? * What percentage of time does your bird spend inside and outside of it's cage? * Is the bird supervised when out of the cage? Please give details * Does your bird have regular exposure to sunlight? * Yes No Unknown Frequency and length of time? * Is your bird exposed to full spectrum (UVA and UVB) lighting? * Yes No Unknown Brand? * What is your bird's light/dark cycle? Does anyone in your household smoke? * Yes No Unknown Do you use any aerosolized products? * Yes No Unknown Please give details * Have there been changes in the bird's environment in the last 3 months? * Yes No Unknown Please give details * Signature * signature keyboard Clear Date * Captcha If you are human, leave this field blank. Submit
