Avian History Form Name or Identification*Common/Scientific species name*Date of Birth* MM slash DD slash YYYY Age*Sex* Male Female Male/Neutered Female/Spayed UnknownOrigin* Captive bred Wild Caught Import UnknownHow long have you had this bird?*From where did you obtain this bird?*Does this bird have a reproductive history?* Yes NoDetails:*Is your bird vaccinated?* Yes NoPlease list vaccines and dates given:*When did your bird last molt?*Does your bird get his/her wings trimmed?* Yes NoDetails*Do you have any other birds/pets in the household?* Yes NoIf yes, list the number and species:*When was the last bird added to your household?*Has your pet had contact with any other birds in the last 30 days?* Yes NoIf yes, when and what species?*Cage EnvironmentCage location* Inside OutsidePercentage of time your bird spends in the cage:*What is the cage made of and what are the dimensions?*Have there been any changes in the environment in the last 3 months?* Yes NoIf yes, give details:*What decor and furnishings are present?* Nest Box Perches Swings Toys OtherOther*Any exposure to direct sunlight?* Yes NoDetails*Is your bird exposed to full spectrum (UVA/UVB) lighting?* Yes NoDetails*What bedding do you use?*Do you provide any bathing facilities?* Yes NoDetails*Bird's day/night cycle*Are there smokers in the house?* Yes NoDo you use aerosolized substances?* Yes NoHow often is the cage cleaned?*DietHow often do you feed your bird?*Which foods are eaten and in what amounts (by weight or approximate volume)?*Nutritional Supplements – Type/Amount/FrequencyWhat water supply do you provide?* Tap water Bottled water Rain/River waterHow is water provided?* Bowl Dripper System SpraySpray (how often)*How often is the water changed?*Do you use any water supplements?* Yes NoDetails*Have you noticed any changes in feeding or drinking behavior?* Yes NoDetails*Have you noticed any changes in the droppings (fecal material/urine/urates)?* Yes NoDetails*Reason for Presentation TodayWhat is the primary complaint or what signs you have noticed?*Has this bird had previous health problems?* Yes NoDetails*Has this bird received any treatment in the last 30 days?* Yes NoDetails (what was used, often, duration)*Have you noticed any changes in this bird's behavior?* Yes NoDetails*Have any other animals or persons in the household had any illnesses within the last 30 days?* Yes NoDetails*Any additional comments or details of relevance?*CommentsThis field is for validation purposes and should be left unchanged.Δ
