Avian Health Questionnaire – First Visit 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: Store Private party Breeder Wild-caught Other (describe) Other (describe) Date acquired: Has the bird been quarantined? Commercial Private 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 cage Aviary Free in the house Indoors Outdoors In a separate room With the family 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: 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 ? YES NO When/Why? Do you have any other questions or concerns: I was referred to your clinic by: NameThis field is for validation purposes and should be left unchanged.
