Avian History Form

General Information

Client Name

First Last

Patient Name

First

Patient Date of birth

Species

Gender

Where did you obtain your bird?

How long have you had your bird?

Number of previous owners (other than breeder/store):

Are there any other animals housed in the same cage/enclosure? If so, what species and genders?

What other pets are kept in the house?

Are there any recent additions to the household?

Has your bird had any contact with other birds in the last 30 days?

What state and/or countries has your pet lived in?

Does your bird have a reproductive history? If yes, please elaborate.

When was the last molt? How often has your bird been molting?

Does your bird get it's wings trimmed?

Environment

Is this animal kept indoors or outdoors?

Describe the cage enclosure (size, type, objects in cage, furnishings, etc.)

What type of material is used to line the bottom of the cage/litter pan.

What percentage of time does your bird spend out of the cage?

Is your pet supervised out of the cage?

Does your bird have regular exposure to direct sunlight? If yes, how frequently/how long?

Is your bird exposed to full spectrum (UVA AND UVB) sunlight?

What is your bird's light/dark cycle?

How often is the cage cleaned?

What is used to clean/disinfect the cage?

Do you spray/bath your bird? If yes, please describe in detail.

Does anyone in the household smoke?

Do you use aerosolized products?

Has there been any changes to your bird's environment lately?

Diet

Which foods does your bird eat (brand/type) and in what amounts (by number, weight, or approximate volume):

How often do you feed your bird?

Do you use nutritional supplements? If so, what, how much, and how often?

What water supply do you provide?

How is water provided?

How often do you provide/change the water?

Reason for Presentation Today

If your pet is here for an illness, please describe the symptoms and how long your pet has been showing them:

How is your pet's activity level?

How is your pet's appetite?

Have you noticed any of the following:

Weight Loss
Weight Gain
Increased breathing rate or effort
Increased thirst
Decreased thirst
Weakness

Previous Conditions

Has your pet had any previous conditions,operations,or problems (including dental or gastrointestinal problems)?

Is your pet currently on any medications? If yes, please describe (medication, dosage, duration, frequency, etc).

General Information

Environment

Diet

Reason for Presentation Today

Previous Conditions

Casselton Location

Fargo Location

Boarding And Grooming – Fargo

Social