Owner Contact Information

Owner name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

First visit
Returning client (new pet)
Returning client/patient

Avian Information

Bird name *

Age

Birthday (if known)

Species *

Sex *

Male
Female
Unknown

Source of bird

Store
Breeder
Adoption/Rescue
Other

Describe *

Date acquired *

Wild-caught
Domestic-bred

Has the bird been quarantined? *

Yes
No
Commercial

Length

Did any of those birds die or become ill during the quarantine? *

Yes
No

Details *

Medical History

Previous illnesses or injuries:

Previous medications:

Any current medications: *

Yes
No

If yes, describe:

Vaccination history

Wing trimming *

Yes
No Method

if known

Date of last examination *

Environment/Husbandry

Bird is kept in

Size and location of bird’s enclosure *

Other birds in same cage or aviary? *

Yes
No

List other birds on the premises, past, or present:

Are any of those birds sick? *

Yes
No

Have any died? *

Yes
No

List other pets in the home or yard:

List toys available to the bird:

What do you use on the bottom of the cage?

Can bird reach it?

Yes
No

How often is the substrate changed?

Frequency of cage cleaning and products used:

Method and frequency of cleaning food and water source:

Sleeping habits:

Hours of darkness: *

Any activity around cage when bird is sleeping?

Exposure to UVB

Direct sunlight
UVB bulb

How many hours: *

What is the current diet (Include brands of products):

Pellets

Seeds

Fresh food

Other (describe):

Volume of food offered:

Pellets

Fresh food

Seeds

Other (describe):

Amount of what bird consumes:

Pellets

Fresh food

Seeds

Other (describe):

How often is food replaced?

How is the bird bathed?

How often?

Behavioral History

Any behavioral issues *

Yes
No

Describe *

How long has it been an issue?

Any previous or current treatments for behavioral issues

Reproductive History

If female, any history of egg laying? *

Yes
No

If yes, when was the last clutch? *

How often does egg laying occur? *

How many eggs are produced? *

Are eggs fertile?

Yes
No

If fertile, are offspring viable when hatched?

Yes
No

Describe any issues:

Current Health Status

Reason for visit: *

Wellness exam (New pet)
Wellness Exam (Return/Annual visit)
Illness/Injury Exam

If ill, describe signs and symptoms *

How long have problems been occurring? *

Any treatments tried?

Yes
No

If yes, what? *

Mark any of the following symptoms seen

Characteristics of droppings

Formed
Diarrhea
Blood
Increased urine

Stool color

Urate color

Other changes/abnormalities

Any other concerns:

Avian History Form