Avian History Questionnaire

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MM slash DD slash YYYY

Name







My bird is



Has your bird ever laid an egg?


I feed my bird (Please check all that apply)




My bird has these symptoms (Please check all that apply)
















Do you have other birds?


Check all statements that apply. My bird is:




At night, my bird is in his cage but,


In a different cage from his day cage


Has your bird been boarded recently, been to a pet store, or place where there are other birds.


Has your bird ever been sick in the past: (Check all that apply)



Various tests may be needed to diagnose your bird’s problems. We often need to start with X-rays and/or an ultrasound exam. In some cases, bloodwork is necessary to help determine the health of your bird. Do we have your permission to do these tests if needed?
X-rays ($125)


Ultrasound ($45)


Bloodwork (typically $125) (We will call if cost exceeds)



MM slash DD slash YYYY

This field is for validation purposes and should be left unchanged.






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