Pre-Register
at Brown County Veterinary Hospital...
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AVIAN EXAMINATION HISTORY FORM
Print this page and fill out before coming
in:
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Your bird's name:______________
Sex: M F
Unknown
Age:___________________________
How was the sex
determined?_______________________________________________________
If your bird is female. have you seen any egg
laying?______________________________________
This bird is a:
Pet
Breeder
Where did you get your gird (breeder, private home, pet
store, surrendered)____________________
If your bird was surrendered to you,
why?_____________________________________________ |
Was you bird
handfed?______________________________________
Was your bird domestically raised or
imported?____________________
How long have you owned your
bird?___________________________
When was your bird's last
molt?_______________________________
Are there other pets in the house? If yes, how many and what
kind?___
_______________________________________________________
Have there been any recent changes in the household? (new people, pets,
remodeling)______________________________________________
Housing
Where is your bird kept, and what percent of the
time_______________
_______________________________________________________
_______________________________________________________ |
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When indoors, what percent of the time is spent in a cage vs. free in the house (supervised/unsupervised)?
_______________________________________________________________________________
Describe your bird's cage (size, shape, toys,
perches).______________________________________
_______________________________________________________________________________
Is your bird housed
alone?___________________________________________________________
If there are other birds, where are they kept in relation to your
bird?__________________________
_______________________________________________________________________________
List day and night temperatures of the
cage.______________________________________________
Is UV light supplied to your bird? What is the
source?______________________________________
What do you cover the bottom of the cage
with?___________________________________________
How often is the cage cleaned and what cleaners are
used?__________________________________
_______________________________________________________________________________
How is your bird bathed? How
often?__________________________________________________
Does anyone smoke inside the
house?__________________________________________________
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Diet
What foods are offered and in what amounts? (e.g., free choice pellets, a piece of
broccoli and a teaspoon of
seeds)_______________________________________________________________________
What foods are accepted by your bird and in what percentage? (e.g., 90% seeds, 10% table
food)_____
_______________________________________________________________________________
What treats are given?_________________________ How
often?__________ How many?_________
Have there been any recent diet changes?
Describe:_______________________________________
How is water offered? (e.g., sipper bottle, bowl, cage
cup)______________________________
Health
Have you noticed any changes in your birds behavior? (e.g., started screaming, became aggressive, started
feather
damaging)_________________________________________________________________
_______________________________________________________________________________
Have you noticed a change in your birds
droppings?________________________________________
Do you have your bird's wings trimmed? If yes,
why?_______________________________________
Is any one in your house immunocompromised? (very young
or old, receiving chemotherapy or an organ
transplant)_______________________________________________________________________
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Reason for today's visit
What signs have you noticed that prompted today's visit?
________________________________________________________________
________________________________________________________________
How long have you noticed the problem?
_________________________________________________________________
_________________________________________________________________
Has your bird been sick previously?______________________________________
Has your bird been seen by another doctor? If yes, when and for what reason?
________________________________________________________________
Have any tests been previously conducted on your bird? (blood work, x-rays, fecal
tests,
other)______________________________________________________ |
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Does your bird take any medications? If yes, what kind and for how
long?______________________
Additional comments, concerns, or
requests:_____________________________________________
______________________________________________________________________________
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