Avian History

Owner's Name:
Address:
Phone:
Patient Name:
Species:
Age:
Sex:
Male Female Unknown
How was this bird's sex identified?
Surgically DNA (feather test) Other (Describe:)
Identification (show number)
Tattoo
Microchip
Band
Bird is a...
Pet Breeder (has produced young or eggs, describe:)
Source of Bird:
Store Private Party Breeder Other (Describe:)
Date acquired?
MM/DD/YYYY
Wild-caught Domestic-Bred
Has the bird been quarantined?
Commercial Private
Length in quarantine:
Was bird isolated prior to introduction to present location?
Yes No
Length in isolation (days)
Other bird species in isolation area?
Give cause, if known, of any bird deaths during isolation period
Present environment:
Cage Aviary Free in House Wings trimmed
Other birds in the same cage or aviary? (describe)
Are any of the other birds sick?
Yes No
If yes, describe:
Have any of the other birds died?
Yes No
If yes, describe:
List toys available to the bird:
What do you use in the bottom of the cage?

Can the bird reach it?
Where is your bird kept?
Indoors Outdoors Separate room With the family
List other birds in the immediate vicinity:
List other birds in the home/aviary:
List other pets in the home:
Frequency of cage cleaning:
Method/frequency of cleaning food/water receptacles:
How many hours of darkness does the bird have each day?
Diet:
Pelleted Seeds Table Food Combination
Describe diet:
Amount offered to bird each day?
Amount bird eats each day?
How is water offered (cup, tube)?
Recently added food or dietary changes?
What signs prompted you to bring in the bird?
Have you noticed (check all that apply):
diarrhea blindness vomiting constipation tail-bobbing
breathing difficulty perching difficulty fainting sitting fluffed up
drooping wings feather picking bleeding lameness
change in personality change in vocalization change in stool consistency
change in appetite excessive water consumption
Describe:
Tests given (check all that apply):
Psittacosis psittacine beak and feather disease polyomavirus parasites
What vaccines has the bird been given and date given?
Has the bird been seen by any other veterinarians?
Yes No
What was used for treatment?
Has the bird been dewormed?
Yes No
When/Why?
Additional comments (Your opinion regarding this illness/accident)
Signature
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