Avian Patient History Form

Avian Patient History Form

Owner Information

Owner Name
Owner Name
How would you like us to contact you?

Pet Information

Sex determined by
Does the bird have a reproductive history?
Is your bird vaccinated?
Does your bird get wings trimmed?
Do you have other birds or pets?
Have you or your bird had any contact with other birds in the past 30 days?
Has your bird received any treatment in the last 30 days?
Have you noticed a change in your bird's behavior?
Have any other animals or persons in the household had any illness in the last 30 days?

Diet Information

Do you use any nutritional supplements?
What water supply do you provide?
Do you use any water supplements?
Have you noticed any changes in feeding or drinking behavior?
Have you noticed any changes in droppings (fecal material, urine and urates)?

Environment Information

Are bathing/spraying facilities provided?
Does your bird have regular exposure to sunlight?
Is your bird exposed to full spectrum (UVA and UVB) lighting?
Does anyone in your household smoke?
Do you use any aerosolized products?
Have there been changes in the bird's environment in the last 3 months?