Patient form

Avian History Form

First Name *

Last Name *

Pet's Name or Identification *

Species *

Age *

Sex of Pet *

Origin *

How sex was confirmed *

How long have you owned? *

Any previous owners? *

Yes No

What is the primary reason you have brought your bird here today? *

When did the problem or signs begin? *

Have any medications been given or treatments been attempted? *

Have there been health problems in the past? *

Do you own other birds or pets? If so, please describe the number of animal and the species housed. *

Have there been any recent introductions of new pets or birds? *

Yes No

If yes, when:

Has the bird presented today had contact with other animals, particularly in the last 30 days? *

Yes No

What is the cage type? *

What is the cage size? *

The cage is made of? *

List all cage furniture, toys, and accessories: *

Describe the number and type of perches: *

What cleaning methods are used? *

What is the frequency of cleaning? *

What is the temperature of the house and room where the bird lives? *

Are there heat sources? *

What is the humidity? *

What light sources are provided? *

Is full-spectrum UV-B or UV-A lighting used? *

Yes No

How old are the full-spectrum lights? How often are they changed?

How many hours of light are provided daily? How many hours of dark per day?

Have any pesticides, aerosol sprays, or chemicals been used in the immediate vicinity of the bird environment? *

Yes No I don't know

Do you have electric or gas heat? *

Is your bird exposed to any smoke (tobacco), essential oils, kitchen oils, or others? *

Have there been any changes in the environment (new house, pet, people, cage location, etc)? *

What is the diet? (What is offered and what is eaten?) Include brand names, and be as specific as possible. *

Where are the food items obtained? *

Please describe the type and frequency of supplimentation. *

What is the frequency and timing of feeding? *

When did the animal last eat? *

Where is food purchased? *

How often is the animal handled? *

Is your bird flighted? *

Yes No

Is your bird exposed to direct sunlight?

Yes No

Does your bird spend time outdoors? *

Yes No

If yes, how often and for how long?

Has your bird laid eggs? *

Yes No

Does your bird have any behavior or aggression issues? *

Owner Name *