Date

Your Name

Your Email

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 provided. Thank you.

Patient Information

Species

Gender

Male

Female

Unknown

Method used to determine gender

Date of hatch (if known)

Date acquired

Source (pet store, breeder, previous owner)

Number of previous owners (other than breeder, 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, other furnishings What is on the bottom of the cage?

Are there are other birds in the house?

Yes

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

List any other pets that you 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 out of the cage?

At All Times

Sometimes

Not

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

List recent changes in the environment, if any

Exposure history

Has your bird been exposed to any birds other than your own?

Yes

Boarding - when, where?

Bird clubs, shows - when, where?

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

Friends' birds, other birds?

Toxins

Does anyone in the house smoke?

Yes

Is your bird exposed to kitchen fumes?

Yes

Do you have non-stick cookware?

Yes

Does your bird chew on houseplants?

Yes

In what year was your house/apartment built?

Does your bird chew on painted surfaces (such as walls or windowsills)?

Yes

Dust

Is there an unusual amount of dust, or any construction near your home?

Yes

Do you have air filtration?

Yes

Please list any air fresheners, cleaning products, deodorizers, or insecticides that are used in the same room as your bird

Please list other possible toxins or irritants

Diet

What percent of your bird's diet consists of the following (please describe what the bird actually eats, not what is offered): % and brand/types

Bird pellets

% and brand(s)

Seed mixture

% and types/brand(s)

Table food

% and types

Other

% and types

How often do you change your bird's food?

Treats: types, frequency

Supplements:

Multivitamin in

Water

Food

Brand, frequency

Minerals

Powder

Cuttlebone

Block

Oyster Shell

Is it eaten?

Yes

Is grit offered?

Yes

Water source

Please describe any recent additions/changes to your bird's diet

Vaccinations

Please list any vaccine(s) that your bird has had and when they were given

Reproductive

Do you plan on breeding this bird?

Yes

Possibly

How many clutches of eggs has your bird laid?

Does your bird lay continuously?

When was the most recent egg?

Was the egg

Normal

This Shelled

Misshapen

How many babies have been hatched from this bird?

Were they healthy?

Yes

Describe any past reproductive problems with offspring

Does your bird have any behavioral problems?

Feather picking

Screaming

Biting, aggression

Fear of people

Other

Previous Conditions, Problems, or Operations (list with date, if known)

Is your bird here for a

well-bird check up

it is sick

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

Is your bird eating normally?

Yes

Have you used any medications from a pet store? (list)

Have you noticed any of the following:

Has your bird been seen by another veterinarian for any of the current problems?

Yes

If yes, when?

Please list tests performed

Please list medications given

Is there anything else you would like done today?

I have questions about

Other

If your bird is hospitalized, may we have permission to trim the wings? This will make medicating your bird less stressful – both in the hospital and at home.

Yes

Did you know that avocado ingestion and fumes from Teflon (and other non-stick surfaces) on cookware, self- cleaning ovens, or heaters can be fatally toxic to pet birds? Please ask us if you need help making your home bird-safe.

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