Avian History Form

Orchard Park Veterinary Medical Center

OPVMC Avian History Form

Instructions: An accurate history of your pet is extremely important. We would appreciate your cooperation in providing us with the following information. Please check the appropriate boxes or use the spaces.

Form - Avian History Form

Name
First Name	Last Name

Address
Street Address


City	State/Province	Zip/Postal Code
,

Phone
Phone Type	Phone Number

Client Identification:

Date of Scheduled Visit:

Patient Information

Species:

Gender :

Method used to determine?

Date of Hatch (if known):

Date acquired:

Source :

Number of previous owners (other than breeder and store):

What states and countries has your bird lived in?

Environment

What room(s) is your bird kept in?

Describe the cage - type, size, perches, toys, and other furnishings:

What is on the bottom of the cage?

Are other birds in the house?
Yes
No

If so, what types are they and when were they acquired?

Please list any other pets you may have:

Do you regulate the temperature near the cage?

How much time does your bird spend outside of the cage?

Is your bird supervised when it is outside of the cage,.... :

Does your bird chew on walls, furniture, or other household objects?

List any recent changes in environment:

Exposure History

Has your bird been exposed to any birds other than your own?
Yes
No

Boarding - when or where?

Bird clubs - when or where?

Has your bird been outside or has a wild bird been in your home?

When? Friend's bird or other birds?

Toxins

Does anyone in the house smoke?
Yes
No

Is your bird exposed to kitchen fumes?
Yes
No

Do you have non-stick cookware?
Yes
No

Does your bird chew on houseplants?
Yes
No

In what year was your house/apartment built?

Does your bird chew on painted surfaces (such as walls or windows)?
Yes
No

Dust: Is there an unusual amount of dust, or any construction near your home?
Yes
No

Do you have air filtration?
Yes
No

Please list any air fresheners, cleaning products, deodorizers, or insecticides that are used:

Please list other possible toxins or irritants:

Diet

What % of your bird's diet consists of the following?
Please describe what the bird actually eats, not what was given.

Bird Pellets %

What brand(s)?

Seed mixture %

Types/Brand(s):

Table Food %

Types

Other - %

Types

How often do you change your bird's food?

Treats: Types & Frequency?

Supplements

Multivitamin in:
Water
Food

Brand & frequency:

Minerals: :

Is it eaten?
Yes
No

Is grit offered?
Yes
No

Water Source

Please describe any recent additions/changes to your birds diet:

Vaccinations

Please list any vaccines that your bird has had and when they were given:

Reproductive

Do you plan on breeding this bird?
Yes
No
Possibly

How many clutches of eggs has your bird laid? Does the bird lay them continuosly?

When was the most recent egg?

Was the egg: :

How many babies have been hatched from this bird?

Were they healthy?
Yes
No

Describe any past reproductive problems or problems with offspring:

Behavioral

Does your bird have any behavioral problems? :

Other:

Previous conditions, problems, or operations (list with date if known):

Is your bird here for a:
Well-being check up
Your pet is sick

If your bird is sick, please describe the signs and how long the bird has been showing them:

Is your bird eating normally?
Yes
No

If no, please describe:

Have you used any medications from a pet store?
Yes
No

If yes, please list:

The verification code below ensures the form is not submitted by a computer

Verification Code :

Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.