AVIAN NEW PATIENT FORM

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Environment and diet play a fundamental role in the health of exotic pets. In order to obtain the best assessment of your pet’s health and therefore provide the most appropriate care, it is very important that we have very detailed information regarding your pet. Please complete this form as thoroughly and accurately as possible. If you are unsure about any questions, please answer to the best of your ability or ask a veterinarian or staff member for clarification.
Client Information
Date:
MM slash DD slash YYYY
How did you hear about us?
Client Name:*
First Last
Spouse/Secondary Name (if applicable):
First Last
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Home Phone:
Work Phone:
Cell Phone:
Email Address:*
Patient Information
Name:*
Species (common & scientific name, if known):
Age:
Sex:
- Male
- Neutered Male
- Female
- Spayed Female
- Unknown
How was the bird sexed? (check all that apply)
- Blood Test DNA
- Surgical (Endoscopy)
- Visually
Color/Markings
Any specific identification? (check all that apply)
- Tattoo
- Leg band
- Microchip
- Other
Please describe ID location and details:
Veterinarian Referral Information
(If referred, the following information must be provided.)
Hospital Name:
Referral Hospital Address
Street Address Address Line 2 City State ZIP Code
Referral Hospital Phone:
Referral Hospital Fax:
Reason For Today's Visit
What signs have you noticed that prompted today's visit?
How long have you noticed the problem?
Has the problem gotten worse, better or stayed the same?
Is your bird currently on any medication?
- Yes
- No
If yes above, please describe:
Have you noticed any of the following signs? (Please mark all that apply and provide details)
- Behavior change
- Change in exercise ability
- Nasal or ocular discharge
- Regurgitation
- Change in stool quality
- Change in urine/urate quality/color
- Change in urine volume
- Lameness/weakness
- Scratching
- Feather abnormalities
- Increased thirst
- Decreased thirst
- Increased appetite
- Decreased appetite
- Weight loss
- Weight gain
- Lethargy
- Sneezing
- Voice change
- Vomiting
- Increased breathing rate or effort
Explain above signs:
Has your bird been sick previously?
- Yes
- No
If yes, please describe:
Has your bird ever been seen by another veterinarian?
- Yes
- No
If yes, please list when/why:
Has any member of your household (human or animal) had an illness in the last month?
- Yes
- No
If yes, please describe:
Additional comments regarding your visit today:
Have any tests been performed previously on your bird? (Check all that apply)
- Psittacosis (Chlamydophila)
- CBC
- Chemistry Panel (organ function tests)
- Polyomavirus
- Psittacine Beak and Feather Disease
- Parasite Examination
- Radiographs (X-rays)
- Other Tests (describe below)
Other Tests Description:
Housing
Is this bird kept:
- Indoors
- Outdoors
- Both (if both, please describe below)
If Both above, Describe Indoor/Outdoor living:
How is your bird housed?
- Cage
- Aviary
- Free in the house
Is your bird allowed outside of the cage?
- Yes
- No
- Third Choice
If yes above, how often?
Is the bird supervised at all times when out of the cage?
- Yes
- No
If no above, please describe:
Is your bird housed alone?
- Yes
- No
If no above, please explain:
If caged, what type/size of cage?
What do you use on the bottom of the cage?
Is a grate present?
- Yes
- No
How often is the cage cleaned? Describe method of cleaning:
How often are the food and water dishes cleaned?
Describe method of cleaning:
What cage furniture is present?
- Perches
- Toys
- Swings
- Nest box
- Other
Please describe the cage layout:
Please describe any bathing/shower activity provided (including how often):
Has your bird's environment changed recently?
- Yes
- No
If yes above, please describe:
What is the night-time procedure for your bird?
- Cage covered
- Placed in nighttime cage
- No change
- Other
If other above, please describe:
How many hours of darkness does your bird have each 24 hour period?
Do you have:
- Candles
- Fireplaces
- Teflon cookware
- Wood or oil burning heater?
General History
How did you acquire your bird?
- Store
- Breeder
- Other
Source:
- Captive bred
- Wild caught (Imported)
- Unknown
Date acquired:
MM slash DD slash YYYY
Age when acquired:
Bird is a:
- Pet
- Breeder
- Other
Has any reproductive activity been noted?
- Yes
- No
If yes above, please describe in detail:
When was your bird’s last routine feather loss?
Is your bird vaccinated?
- Yes
- No
If yes above, please list vaccines and dates:
Do you have your bird’s wings trimmed?
- Yes
- No
If yes above, please describe your trim technique preference:
Do you have any other birds/pets?
- Yes
- No
If yes, please specify species, including ages and when acquired:
Has there been any contact between humans or birds in your household with any other birds in last 1-3 months?
- Yes
- No
If yes above, please describe:
Does your bird have any exposure to full spectrum (UV A or B) lighting?
- Yes
- No
If yes above, which type:
- Direct sunlight
- Sunlight through window
- Special bulbs (please describe below)
Describe special bulbs
Do any smokers live in the house or visit regularly?
- Yes
- No
If yes above, please describe:
Is any of the following present in your home? (Please mark all that apply)
- Sprays (air fresheners, insecticides, cleaning products, etc.)
- Houseplants to which your bird has access
- Painted or linoleum surfaces to which your bird has access
- Dust (within the home or nearby construction)
- Any other possible toxins or irritants?
Diet
How often is food offered to your bird?
What specific types of foods are offered to your bird? In what total percentages are they given?
Seed Mix – Brand/type:
Amount of Seed Mix given Percent of daily diet:
Pellets – Brand:
Amount of Pellets given Percent of daily diet:
Vegetables/Fruit – Type:
Amount of Vegetables/Fruit given/Percent of daily diet:
What kind of Vegetables/Fruit?
- Fresh
- Frozen/thawed
- Dehydrated
- Other
Proteins (tofu, meat, eggs, cheese) – Type:
Amount of proteins given/Percent of daily diet:
Treats – Type:
Amount of treats given/Percent of daily diet:
Any other foods?
Amount of other foods given/Percent of daily diet:
How much of these foods are actually consumed daily?
Any supplements offered?
- Yes
- No
If yes above, which brand and how often?
Any recent diet changes or new foods?
- Yes
- No
If yes above, please describe:
How is water offered?
- Bowl
- Sipper bottle
- Other
Which water source do you provide?
- Tap
- Bottled
- Well
- Rain
How often is the water changed?
Signature
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Email
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AVIAN NEW PATIENT FORM

Client Information

Patient Information

Veterinarian Referral Information

Reason For Today's Visit

Housing

General History

Diet