Avian Health Questionnaire – First Visit in Nepean, ON

Owner’s Name

Date

Address

Postal Code

Phone numbers (home)

(cell)

(work)

Email

Emerg. Contact(other than immediate family):

ph:

Pet’s Name

Breed

Colour

Sex

Male
Female
Unknown

Age or Hatched Date

Other (describe)

Permanent Identification: Band :

Microchip:

Bird is :

A pet
Used for breeding ( describe ) :

Used for breeding ( describe ) :

Source of bird:

Other (describe)

Date acquired:

Has the bird been quarantined?

Commercial
Private
Length of quarantine:

Length of quarantine:

Other birds kept in the same quarantine ?

Did any of those birds die or become ill during that quarantine period?

Give details:

Present environment:

How do you house your bird?

Are your birds wings trimmed ?

Yes
No

Is your bird housed with other birds ?

Yes
No

Describe:

Other birds on the premises (pets/wild life/poultry)

Are /were any of those birds

Sick
Recently deceased , if so list details :

Recently deceased , if so list details :

Other pets /animals in the house or yard ?

List toys available to the bird:

What do you use on the bottom of the cage?

Can the bird reach it?

Yes
No

Frequency of cage cleaning:

Method/frequency of cleaning food/water receptacles :

How many hours of darkness does the bird have each day?

Describe Diet and amount offered each day:

Pelleted food (brand)

Seeds

Table foods /fresh fruit and veggies

Percentage your bird actually eats each day:

Pellets %

Seeds %

Table food %

Do you give your bird a vitamin supplement?

How is water offered (dish , tube )

Recently added food o r dietary changes:

What signs have you noticed recently:

Describe any other issues :

What tests has your bird had ?

Chlamydia
Psittacine Beak and Feather Disease
Pacheco’s Disease
Polyoma virus
Fecal Test
Blood test (type)

Blood test (type)

Has your bird been seen by any other veterinarian ?

YES
NO
When/Why?

When/Why?

Do you have any other questions or concerns:

I was referred to your clinic by:

Name

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

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Avian Health Questionnaire – First Visit

Describe Diet and amount offered each day:

Percentage your bird actually eats each day: