Avian History Form Your Pet’s InformationName* First Last Species or common nameDate of birth or estimated age*Origin*Captive bredWild caughtUnknownSexDetermined by?*DNAVisualOtherHow long have you had your pet?From where did you obtain your pet?Do you have other pets or birds in the household?*NoYesIf yes, please list number and species*Have you or your bird had any contact with other birds in the last 30 days?*YesNoIf yes, give details*When was the last bird added to your collection?*Cage DetailsWhere is the cage located?*InsideOutsideWhat are the dimensions of the cage and what is it made out of?*What is in the cage set up (décor, toys, ventilation, etc)? Substrate?*How often do you clean the cage and what do you clean it with?What percentage of the time does your bird spend in the cage?Is your bird supervised when out of the cage?YesNoAre there are any smokers in the house?YesNoDo you use aerosolized substances?YesNoDoes your bird have regular exposure to sunlight?YesNoDoes your bird have exposure to UVA and UVB lighting?YesNoWhat is your bird’s day and night cycle (hours of sleep)?Have there been any changes in the environment in the last 3 months?*YesNoIf so, please explain:Diet DetailsHow often do you feed your bird?Please indicate which foods are eaten and the approximate volume:Pellets*YesNoType and amount*Seed*YesNoType and amount*Vegetables*YesNoType and amount*Fruits*YesNoType and amount*Meat products?*YesNoType and amount*Treats/othersDo you use any nutritional supplements in food or water?*YesNoIf yes, what is it, how much, how oftenWater DetailsWhat water supply do you provide?*City tap waterBottled waterWell waterHow is water provided?*BowlDripper systemHow often is the water changed?Reason for Visit todayWhat is the primary reason why you brought your pet in to see veterinarian today?*Have you noticed any changes in feeding or drinking behavior?*YesNoIf yes, please give detailsHave you noticed any changes in droppings?*YesNoIf yes, please give detailsHave you noticed any changes in your bird’s behavior?*YesNoIf yes, please give detailsHas your pet had any previous health problems OR reproductive problems?*YesNoIf yes, please give detailsHave any other animals or people in your household had any illness within the last 30 days?*YesNoIf yes, please give detailsWhat are your pet’s current medications? Has your pet received any medications or treatments in the last 3 months (what was used, dosage, how often and duration):
