Avian History Form Avian History Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Owner Personal Information use of? history? Name *FirstLastEmail *Patient InformationAvian name or identificationCommon or scientific species nameDate of birthAgeSexMFNeutered/SpayedUnknownDetermined byDNAEndoscopyVisualOtherOriginCaptive bredWild caught importUnknownHow long have you had this bird?From where did you obtain this bird?Does this bird have a reproductive history?NoYesWhen did your bird last molt?How often has your bird been molting?Is your bird vaccinated?NoYesDoes your bird get wing trimmed?NoYesDo you have other birds or pets?NoYesHave you or your bird had any contact with other birds in the last 30 days?NoYesWhen was the last bird added to your collection?Reason for VisitWhat is the primary complaint or what signs have you noticed? How long have these problems been present?What health problems has your bird had previously?Has your bird received any treatment in the last 30 days?YesNoHave you noticed any change in your bird's behavior?YesNoHave any other animals or persons in the household had any illness in the last 30 days?Cage EnviormentWhere is the cage located?InsideOutsidePlease give detailsWhat is the cage made of?Cage sizeWhat kind of bedding is used?What décor and furnishings are present?Nest boxPerchesSwingsToysOtherPlease give detailsAre bathing/spraying facilities provided?NoYesHow often is the cage cleanedWhat cleaning/disinfectant agents are usedWhat percentage of time does your bird spend inside of its cageWhat percentage of time does your bird spend outside of its cageIs the animal supervised when out of the cage?YesNoDoes your bird have regular exposure to sunlight?YesNoIs your bird exposed to full spectrum (UVA and UVB) lighting?:YesNoWhat is your bird's light/dark cycle?Does anyone in the household smoke?YesNoDo you use any aerosolized products?YesNoHave there been changes in the bird's environment in the last 3 months?YesNoDietHow often do you feed your animal?Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume)Seed mixturesPelletsFruits and/or vegetablesMeatTreatsOtherDo you use any nutritional supplements?YesNoWhat water supply do you provide?Tap waterBottled waterRain/river waterHow is water provided?BowlDripper systemSprayHow often?How often is the water changed?Do you use any water supplements?NoYesHave you noticed any changes in feeding or drinking behavior?NoYesHave you noticed any changes in droppings (fecal material, urine and urates)?NoYesUpload Photo(s) Click or drag a file to this area to upload. Submit Now
