Avian History Questionnaire

    Date:

    Your Name:

    What is your bird’s name?

    How old is your bird?

    How long have you had your bird?

    My bird is:
    MaleFemaleUnknown

    Has your bird ever laid an egg?
    YesNo

    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

    Other:

    Do you have other birds?
    YesNo

    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,
    CoveredUncovered

    In a different cage from his day cage
    CoveredUncovered

    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)
    YesNo

    Ultrasound $45
    YesNo

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

    *Signature:

    Date:

    Best Contact Phone Number: