Avian History Form Avian History Form Your Pet’s InformationName* First Last Species or common name Date of birth or estimated age* Origin* Captive bred Wild caught Unknown Sex Determined by?* DNA Visual Other How long have you had your pet? From where did you obtain your pet? Do you have other pets or birds in the household?* No Yes If yes, please list number and species*Have you or your bird had any contact with other birds in the last 30 days?* Yes No If yes, give details*When was the last bird added to your collection?* Cage DetailsWhere is the cage located?* Inside Outside What 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? Yes No Are there are any smokers in the house? Yes No Do you use aerosolized substances? Yes No Does your bird have regular exposure to sunlight? Yes No Does your bird have exposure to UVA and UVB lighting? Yes No What is your bird’s day and night cycle (hours of sleep)? Have there been any changes in the environment in the last 3 months?* Yes No If so, please explain: Diet DetailsHow often do you feed your bird? Please indicate which foods are eaten and the approximate volume:Pellets* Yes No Type and amount* Seed* Yes No Type and amount* Vegetables* Yes No Type and amount* Fruits* Yes No Type and amount* Meat products?* Yes No Type and amount* Treats/others Do you use any nutritional supplements in food or water?* Yes No If yes, what is it, how much, how oftenWater DetailsWhat water supply do you provide?* City tap water Bottled water Well water How is water provided?* Bowl Dripper system How 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?* Yes No If yes, please give detailsHave you noticed any changes in droppings?* Yes No If yes, please give detailsHave you noticed any changes in your bird’s behavior?* Yes No If yes, please give detailsHas your pet had any previous health problems OR reproductive problems?* Yes No If yes, please give detailsHave any other animals or people in your household had any illness within the last 30 days?* Yes No If 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):
