Row concave Shape Decorative svg added to bottom Avian History Form Avian History Form Client Information Owner's Name * Owner's Name First Name First Name Last Name Last Name Spouse/Other Spouse/Other First Name First Name Last Name Last Name Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Number Cell Phone Email 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 OtherOther Origin - Please Select -Breeder/captive bredWild caughtPet storeImportedUnknown How long have you had this bird? From where did you obtain this bird? Does this bird have a reproductive history? - Please Select -YesNo Please give details When did your bird last molt? How often has your bird been molting? Is your bird vaccinated? - Please Select -YesNo Please give details Do you have other birds or pets? - Please Select -YesNo 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? - Please Select -YesNo Please give details (what was used, dosage, how often, duration) Have you noticed any change in your bird's behavior? - Please Select -YesNo Please give details Have any other animals or persons in the household had any illness in the last 30 days? - Please Select -YesNo 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? - Please Select -Bottled waterRain/riverWell water How is water provided? Water Storage Bowl Dripper system Spray OtherOther How often? How often is the water changed? Do you use any water supplements? - Please Select -YesNo Please give details Have you noticed any changes in feeding or drinking behavior? - Please Select -YesNo Please give details Have you noticed any changes in droppings (fecal material, urine and/or urates)? - Please Select -YesNo Please give details Do you use any nutritional supplements? - Please Select -YesNo If yes what, how much, and how often? Cage Environment Cage size Where is the cage located? - Please Choose -IndoorsOutdoors 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 Select -YesNo 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 Select -YesNo Please give details Does your bird have regular exposure to sunlight? - Please Select -YesNo Frequency and length of time Is your bird exposed to full spectrum (UVA and UVB) lighting? - Please Select -YesNo Brand? What is your bird's light/dark cycle? Does anyone in the household smoke? - Please Select -YesNo Do you use any aerosolized products? - Please Select -YesNo Do you use Teflon pans? - Please Select -YesNo Do you use a self cleaning oven? - Please Select -YesNo Last self-clean cycle? Have there been changes in the bird's environment in the last 3 months? - Please Select -YesNo Please give details Submit If you are human, leave this field blank.
