Avian History Form Animal DetailsAvian name or identificationCommon or scientific species name:Date of Birth MM slash DD slash YYYY Age(can be approximate) Sex Male Female Unknown Determined by DNA Endoscopy Visual Other Origin captive bred wild caught import unknown How long have you had this bird?From where did you obtain this bird?Does this bird have reproductive history? Yes No Please give details of Reproductive historyWhen did your bird last molt?How often has your bird been molting?Does your bird get wing trimmed? Yes No Please give details of Wing trimmingDo you have other birds or pets? Yes No Please give details of your other petsHave you or your bird had any contact with other birds in the last 30 days? Yes No Please give details of pet contact with other petsWhat health problems has your bird had previously?Prior Vet Clinic NamePrior Vet Clinic Phone #:REASON FOR PRESENTATION TODAYWhat is the primary complaint or what signs have you noticed? How long have these problems been present?Have any other animals or persons in the household had any illness in the last 30days?Has your bird received any treatment in the last 30 days? Yes No Please give details (what was used, dosage, how often, duration)Have you noticed any change in your bird’s behavior? Yes No Please give details of change of behaviorWhen was the last bird added to your collection?DietHow often do you feed your animal?Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume):Seed mixtures Seed mixtures Brand of Seed MixtureAmount of Seed MixturePellets Pellets Brand of PelletsAmount of PelletsFruits and/or vegetables: Fruits and/or vegetables Type of FruitsAmount of Fruits and/or vegetablesMeat Meat Type of MeatAmount of MeatMeat served should be: Freshly killed Frozen/thawed Live prey Treats Treats Brand of treatsAmount of treatsOthers Others Please specify others foodDo you use any nutritional supplements? Yes No Please give details of nutritional supplementsHave you noticed any changes in feeding or drinking behavior? Please give detailsHave you noticed any changes in droppings (fecal material, urine and urates)? Please give details:Cage EnvironmentWhere is the cage located Inside Outside Please give details about cage location?What is cage made of?Cage sizeWhat kind of bedding is used?What décor and furnishings are present? Nest box Preaches Toys Swings What décor and furnishings are present?Are bathing/spraying facilities provided? Yes No Please give details of Bathing / spraying facility in cage?How often is the cage cleaned?What cleaning/disinfectant agents are used?What percentage of time does your bird spend inside and outside of its cage? Inside Outside Is the animal supervised when out of the cage? Yes No Please give details of animal supervisionDoes your bird have regular exposure to sunlight? Yes No Frequency and length of time exposure to sunlightIs your bird exposed to full spectrum (UVA and UVB) lighting? Yes No Brand of UVA & UVB lightingWhat is your bird’s light/dark cycle?Does anyone in the household smoke? Yes No Do you use any aerosolized products? Yes No Do you have non-stick cookware? Yes No Is your bird exposed to kitchen fumes? Yes No Have there been changes in the bird’s environment in the last 3 months? Yes No Please give details of change in bird environment in last 3 monthsIs there anything else you would like done today? Select All Nail trim Wing trim Beak trim Any other service? Any other Question?
