Avian History Form

A detailed history is essential to provide the most appropriate veterinary care for your animal. Please complete this form as accurately as possible. If there is anything you are unsure about you can discuss it in more depth with the veterinary staff during your appointment.

Client Information

Animal Details

Avian name or identification:

Common or scientific species name:

Date of birth:

Age:

Sex: M M Neutered F F Spayed Unknown

Determined by: Endoscopy DNA Visual Unknown

Origin:

How long have you had this bird?

From where did you obtain this bird?

Does this bird have a reproductive history?

Please give details:

When did your bird last molt?

How often has your bird been molting?

Is your bird vaccinated?

Please give details:

Does your bird get wing trimmed?

Please give details:

Do you have other birds or pets?

Please give details:

Have you or your bird had any contact with other birds in the last 30 days?

Please give details:

When was the last bird added to your collection?

Reason for Presentation Today

What 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?

If yes, please give details (what was used, dosage, how often, duration):

Have you noticed any change in your bird's behavior?

Please give details:

Have any other animals or persons in the household had any illness in the last 30 days?

Diet

How often do you feed your animal?

Indicate which foods are eaten and in what amounts (by number, weight, or approx.. volume):

Seed mixtures:

Pellets:

Fruits and/or vegetables:

Meat:

Treats:

Other:

What water supply do you provide?

How is water provided?

Bowl dripper system spray How often?

How often is the water changed?

Do you use any water supplements?

Please give details:

Have you noticed any changes in feeding or drinking behavior?

Please give details:

Have you noticed any changes in droppings (fecal material, urine and/or urates)?

Please give details:

Do you use any nutritional supplements?

if yes what, how much, and how often?

Cage Environment

Cage size:

Where is the cage located?

Please give details:

What is the cage made of?

What kind of bedding is used?

What décor and furnishings are present? nest box perches swings toys other

Please give details:

Are soaking/bathing facilities provided?

Please give details:

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

Please give details:

What percentage of time does your bird spend inside and outside of its cage?

Is the animal supervised when out of the cage?

Please give details:

Does your bird have regular exposure to sunlight?

Frequency and length of time

Is your bird exposed to full spectrum (UVA and UVB) lighting?

Brand?

What is your bird's light/dark cycle?

Does anyone in the household smoke?

Do you use any aerosolized products?

Do you use Teflon pans?

Do you use a self cleaning oven?

Last self-clean cycle?

Have there been changes in the bird's environment in the last 3 months?

Please give details:

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