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Avian History/Husbandry Worksheet
Please answer the following questions as accurately as possible. The more information you provide, the better we can help you and your bird. We realize this is long and appreciate your time and efforts.
Todays date
*
First Name
*
Last Name
*
Pet Name
*
Pet Birthdate
*
Pet Species
*
Pet Breed
*
Pet Sex
*
General information
How was your bird’s sex identified?
*
A
Surgical
B
DNA
C
Other
Does your bird have:
*
A
Tattoo
B
Microchip
C
Band
D
None of the above
How long have you had your bird?
*
Where did you acquire your bird?
*
Is your bird used to being handled?
*
A
Yes
B
No
Are you comfortable giving your bird medications
*
A
Yes
B
No
Are you comfortable weighing your bird on a scale
*
A
Yes
B
No
Are you comfortable Trimming your bird’s wings or nails
*
A
Yes
B
No
Are you comfortable picking up your bird
*
A
Yes
B
No
Would you be interested in training information/guidance?
*
A
Yes
B
No
If yes, which ones?
Group Classes
Private sessions
Webinar
Written instructions
Video
Medical information
What is the primary reason for your visit today?
*
How long have you noticed the problem that prompted today’s visit? ie: when did you first notice the problem?
*
Does your bird have any history of illness or injury? Please describe
*
Has your bird been seen by another veterinarian?
*
A
Yes
B
No
Is the problem getting:
*
A
Worse
B
Better
C
Same
D
None of the above
Have you noticed any of the following signs? (check all that apply)
*
Behavior change
Lethargy / change in exercise
Nose or eye discharge
Sneezing
Increased breathing rate or effort Change in voice / vocalization Vomiting / regurgitating
Change in stool appearance or amount
Change in urine / urate quality / color / volume
Vomiting
Diarrhea
Lameness / weakness
Change in thirst
Change in appetite
Change in weight
Scratching
Feather loss / abnormalities
Skin lumps (masses)
None of the above
Have there been any changes in your home?
*
New pets
New people
New furniture, carpet, flooring
New appliances
We moved - everything is new
We moved the cage to another part of the house
None of the above
Other
Has your bird been anywhere new in the past 3 months?
*
Boarding
Traveling
Bird Show
Bird Meeting
None of the above
Other
Is your bird currently taking any medications? If yes, please list:
*
Have you tried over the counter supplements or remedies? If yes, please list:
*
Housing Information
Does your bird have a cage mate?
*
A
Yes
B
No
How many other birds do you have?
*
Have you acquired any new birds within the past 6 months?
*
Where does your bird live? Check all that apply
*
Inside
Outside
Aviary
Cage
Free in home
Kitchen
Living Room
Office
Bedroom
Other
Are your bird’s wings clipped?
*
A
Yes
B
No
Do you mist or bathe your bird?
*
A
Yes
B
No
How much time does your bird spend outside of it’s cage?
*
Does it chew on anything outside of it’s cage? If yes, please describe.
*
What type of substrate do you use in your bird’s cage?
*
A
paper
B
gravel
C
corn cob
D
walnut shell
E
Other
How often do you clean your bird’s cage?
*
A
Daily
B
Weekly
C
Monthly
D
I’m supposed to clean it?
E
Other
What do you use to clean it?
*
Diet Information
What do you feed your bird? Check all that apply.
*
seeds
pellets
fresh vegetables
fruit
other foods
treats?
Other
Do you give your bird vitamins?
*
A
Yes
B
No
If so, what kind? How do you give them (on food, in water, other)? How often?
How often are food and water dishes changed?
*
A
Twice daily
B
Once daily
C
Every other day
D
Weekly
E
I just add more food to the bowl, why change it?
F
Other
How much do you feed your pet?
*
A
Measured amount
B
Free Choice ie: food always available
How is water offered?
*
A
Bottle
B
Bowl
C
Other
How do you clean the food and water “dishes”?
*
Rinse only
With soap, by hand
Dishwasher
Other
Submit