Avian Physical Examination Questionnaire Form Owner’s Name Date MM slash DD slash YYYY Address Postal Code Phone numbers (home) (cell) (work) Emerg. Contact(other than immediate family): ph: Pet’s Name Breed Colour Sex Male Female Unknown Age or Hatched Date Sex confirmed by? DNA (feather/blood) Other (describe) Other (describe) Permanent Identification: Band: Microchip: What types of food are you feeding? Pellets – Brand(s) % of diet Fresh fruit and veggies (types) % of diet Grains and nuts (types) % of diet Other table food % of diet Seeds – Brand(s) % of diet What does your bird actually eat? What is your bird’s feeding schedule? Does your bird have any foraging toys or opportunities to work for his/her meals? Describe: sleeping out of cage interacting with family members Does your bird spend any time outdoors? YES NO How long/often Do you have any questions or concerns about your bird’s behavior Does your bird board or have contact with other birds? YES NO Describe: Do you have any other questions or concerns? NameThis field is for validation purposes and should be left unchanged.