Avian History Form

Phone

This field is for validation purposes and should be left unchanged.

Email(Required)

Today's Date(Required)

Patient Information

Species(Required)

Method used to determine(Required)

Date of Birth/Hatch (if known)(Required)

Date Acquired(Required)

Source (pets tore, breeder, previous owner, etc.)(Required)

Number of previous owners (other than breeder, store)(Required)

What states and countries has your bird lived in?(Required)

Environment

What is on the bottom of the cage?(Required)

Describe the cage (type, size, perches, toys, other furnishings)(Required)

Where is your bird kept in the house?(Required)

If so, what types are they and when were they acquired?(Required)

List any other pets that you have

How much time does your bird spend outside of the cage?(Required)

List recent changes in the environment, if any

Exposure History

Boarding - please specify when and where(Required)

Bird Clubs or Shows - please specify when and where(Required)

Outside or a wild bird in your home - please specify when(Required)

Friends' bird or other birds - please specify when and where(Required)

Toxins

Please specify(Required)

In what year was your house/apartment built?(Required)

Please list any air fresheners, cleaning products, deodorizers, or insecticides that are used in the same room as your bird(Required)

Please list any other possible toxins or irritants(Required)

Diet

What percent of your bird's diet consists of the following (please describe what the animal actually eats, rather than what is offered)

Bird pellets (list brands and percentage of diet)(Required)

Seed mixture (list types/brands and percentage of diet)(Required)

Table food (list types and percentage of diet)(Required)

Other (list types and percentage of diet)(Required)

How often do you change your bird's food?(Required)

Plesae list all types of treats and how often they are give(Required)

Supplements

Multivitamin (list how they are given, brand, and frequency)(Required)

Minerals (list type and how they are given)(Required)

Water source(Required)

Please describe any recent additions/changes to your bird's diet(Required)

Vaccinations

Please list any vaccine(s) your bird has had and when they were given(Required)

Reproduction

How many clutches of eggs has your bird laid (if none, put n/a)?(Required)

When was the most recent egg?(Required)

How many babies have been hatched from this bird?(Required)

Describe any past reproductive problems or problems with offspring(Required)

If other, please specify(Required)

Previous conditions, problems, or operations (list with date, if known)

If your bird is sick, please describe the signs and how long your bird has been showing these signs(Required)

If yes, please list(Required)

If yes, when?(Required)

Please list tests performed(Required)

Please list medications given(Required)

Is there anything else you would like done today?

Did you know that avocado ingestion and fumes from Teflon (and other non-stick surfaces) on cookware, self-cleaning ovens, or heaters can be fatally toxic to pet birds? Please ask us if you need help making your home bird-safe.