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Forms
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Avian History Form
Avian History Form
Client Name
*
First
Last
Date
MM slash DD slash YYYY
Animal Name
Species
Age
Sex
Pet Animal/Breeder
Pet Animal
Breeder
Owners Information:
Owners Information:
Enter your name (Required)
*
Enter email (Required)
*
Background Information:
Length of time owned
Where acquired?
Breeder
Pet Store
Other
Other
How often is animal handled?
Daily
Occasionally
Never
Animal ever taken outside?
No
Yes
If yes, for how long?
Does your bird have reproductive history?
No
Yes
If yes, specify
Current fecal color & consistency?
Husbandry:
Type of caging
Size of cage
Where is cage located?
Cage furniture
Cage substrate
Type of perches
How often are perches rotated?
% of time spent outside of cage
Inside %:
Outside %:
Is animal supervised when out of cage?
No
Yes
If yes, specify
Are bathing/spraying facilities provided?
No
Yes
If yes, specify
Frequency of cage cleaning?
Type of disinfectant used to clean cage?
Cage Environment:
Light/Dark cycle
Full spectrum lighting?
Brand
Does your bird have regular exposure to sunlight?
No
Yes
If yes, frequency and length of time
Does anyone in the household smoke?
No
Yes
Do you use any aerosolized products?
No
Yes
Do you cook with Teflon?
No
Yes
Nutrition:
How often do you feed your bird?
Select which foods are eaten and describe what amounts (by #, %, weight, or approx. volume):
Seed mixture
Brand
Amount
Pellets
Brand
Amount
Fruits and/or Vegetables
Type?
Amount?
Meat
Type
Freshly Killed
Frozen/Thawed
Live prey
Amount?
Treats
Brand?
Amount?
Other
Do you use any nutritional supplements?
No
Yes
If yes, specify what, how much, and how often
Water Source(s)
How often is it changed?
Any other pets?
No
Yes
If yes, specify
Any other birds?
No
Yes
If yes, specify
Birds are housed together or singly
If not housed together, where are other birds located?
Any new additions to the bird population?
No
Yes
If yes, specify
Past Medical History/Problems
Current Presenting Problem
Duration of Complaint
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2
Meet with a doctor for an initial exam.
3
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