Avian History Questionnaire


    Your Name:

    What is your bird’s name?

    How old is your bird?

    How long have you had your bird?

    My bird is:

    Has your bird ever laid an egg?

    I feed my bird: (Please check all that apply)
    Pelleted DietTable FoodPeanutsSeed Mix

    What is the main reason for your bird’s visit today:

    My bird has these symptoms: (Please check all that apply)
    ListlessDrinking a lotDrinking nothing Eating more than normalEating less than normalNot eating anythingLoose droppings / diarrheaVomitingSleeping more than normalVoice has changed or stopped talkingHaving trouble breathingTrouble perchingPicking feathersChewing skin and making it bleedFainting or seizure


    Do you have other birds?

    If so, how many?

    What kind?

    Check all the statements below that apply:
    My bird is:
    Always in his cageOut of the cage but in a confined area or on a perchLoose to run around the houseSometimes outside

    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)
    Never sickSick and treated by a VeterinarianSick but got well with medication from pet store or without treatment.

    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 $125.00 (sedation required)

    Ultrasound $45

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



    Best Contact Phone Number: