Client Details

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Alternative Phone Number

Email Address

Bird Details

Name

Species

Age (date of birth)

Sex

Address where bird is kept

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date acquired

Source (pet shop, friend, breeder, etc)

Details of Other Pets

Do you have any other birds? If yes, please provide details (name, date acquired, source, any known illness)

What exposure does the bird have to other birds?

Do you have any other pets? If yes, please provide details (species, date acquired, source, any known illness)

Are there any ill family members in the household? If yes, please provide details

Husbandry

Does your bird have access to the entire house? (If your bird is confined to one room, please give details)

What is the temperature in the house (day/night)?

Has your bird damaged any household items? If yes, please provide details (item, how and when it was damaged)

Is your bird kept in a cage? If yes, please specify approximate dimensions

What material is your bird’s cage made out of?

Please describe the bedding used in the cage

How often do you change the bedding?

What disinfectants are used in the cage and how often?

Is your bird allowed outside? If yes, is it supervised?

Is the photoperiod natural and regulated, or random and irregular?

Are there any smokers in the household?

Is your bird potentially exposed to any aerosols (household chemicals, disinfectants, hairspray etc)?

Has there been any recent changes in the home (new enclosure, different diet, painted house, new carpet/floor, moved to a new house, new pet/people in the house, moved location of cage etc)?

Sleeping Habits

Hours of Darkness

Covered
Uncovered
Sleeping in Cage

Food

Please describe your bird’s diet, list all the items he/she is known to eat and the quantities of these items

Is your bird’s food a commercial food? If yes, please name the brand

Do you offer table food to your bird? If yes, please specify what is offered and how often

What is your feeding schedule?

Has there been a recent change in diet? If yes, please specify

Are any of the following given to your bird?

Vitamins
Minerals
Medicines
Probiotics

Water

Has the drinking increased or decreased as of late? If yes, when did you notice?

Any changes to water consumption

General Info

Have there been any previous health issues with your bird? (If yes, please provide details including dates)

If female when was the last time she laid eggs and number in clutch

The Presenting Health Concern

Please describe your bird’s clinical symptoms

Have you noticed any of the following

Are the droppings normal in appearance and size? If not, please specify

Is the skin condition normal?

Has there been any excessive scratching?

Is there any odd positioning or loss/limited of use of any limbs? If yes, please specify

Has there been any abnormal vocalization?

Any additional comments

Avian History Form

Client Details

Bird Details

Details of Other Pets

Husbandry

Food

Water

General Info

The Presenting Health Concern

About Us

Regular Clinic Hours

Location

Directions