Avian Health History Questionnaire

Bird Name:

Type of Bird:

breed of bird/scientic name

Gender:

Male
Female
Altered/Spayed or Neutered
Unknown

Please check all that apply.

Age

How long have you had the bird?

From where did you obtain the bird?

Pet Store
Breeder
Rescue
Former Owner
other

Does your pet have reproductive history?

Yes
No

If yes please give details:

Does your pet get regular wing trims?

Yes
No

Do you have other birds or pets in the house?

Yes
No

If yes, please give details

Have you or your bird had any contact with other birds in the last 30 days?

Yes
No

If yes, please give details

Reason for appointment today:

Please give details on complaint today, signs you have noticed and how long these signs have been present. Any previous health issues? Any other animals or humans had health issues in last 30 days?

DIET:

Please fill out information today to the best of your knowledge.

How often are you feeding your bird?

Type of Food:

Please specify what types of food are eaten and amount of each. (seed mixtures/brand, pellets brand, fruits & vegetables, meat)

Type of treats:

Please specify what type of treats and how much you are giving.

How is water provided?

Bowl
Dripper System/Spray
Water Bottle

How often is the water changed?

Has there been any changes in appetite or thirst?

Has there been any changes in droppings?

fecal consistency, change in urine

CAGE ENVIRONMENT

Where is the cage located?

Inside
Outside

What is the cage made of? Size?

What type of bedding is used? furnishings?

What type of toys, bedding and furnishings in cage?

Are you bathing/spraying bird?

Yes
No

If yes, please give details.

What types or baths? Soap? Spray bottle?

Please specify percentage of time bird spends inside and outside of the cage.

Inside? Outside?

Is your bird supervised when he is outside the cage?

Yes
No

Does your bird have regular exposure to sunlight?

Yes
No

What is your birds light and dark cycle?

How long is your bird covered and uncovered?

Does anyone in the household smoke/vape?

Yes
No

Please list aerosolized products below.

Has there been any changes in the birds environment in the last 3 months?

Yes
No

If yes, please explain:

Monday	8:00am – 5:30pm
Tuesday	8:00am – 5:30pm
Wednesday	8:00am – 5:30pm
Thursday	8:00am – 5:30pm
Friday	8:00am – 5:30pm
Saturday	Closed
Sunday	Closed

Avian Health History Questionnaire