Avian Health Questionnaire – First Visit Owner’s NameDateAddressPostal CodePhone numbers (home)(cell)(work)Email Emerg. Contact(other than immediate family):ph:Pet’s NameBreedColourSexMaleFemaleUnknownAge or Hatched DateOther (describe)Permanent Identification: Band :Microchip:Bird is :A petUsed for breeding ( describe ) :Used for breeding ( describe ) :Source of bird:StorePrivate partyBreederWild-caughtOther (describe)Other (describe)Date acquired:Has the bird been quarantined?CommercialPrivateLength 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?In a cageAviaryFree in the houseIndoorsOutdoorsIn a separate roomWith the familyAre your birds wings trimmed ?YesNoIs your bird housed with other birds ?YesNoDescribe:Other birds on the premises (pets/wild life/poultry)Are /were any of those birdsSickRecently 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?YesNoFrequency 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)SeedsTable foods /fresh fruit and veggiesPercentage 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: Fluffed up (fluffed feathers) Change in appetite Vomiting Sleeping more Change in droppings Change in personality Tail-bobbing Breathing difficulty Perching difficulty Fainting Skin bleeding Feather picking or feather loss Drooping/injured wings or legs Eye/nostril/ear bleeding or injury Excessive water consumption Bitten by other bird or pet Lameness Constipation Change in vocalization Blindness 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 ?YESNOWhen/Why?When/Why?Do you have any other questions or concerns:I was referred to your clinic by:EmailThis field is for validation purposes and should be left unchanged.
