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Avian Medical History

Owner's Name *

First

Last

Account #:

Today's Date

Appointment Date and Time (if already scheduled)

Date

Time

Email *

Phone

Address

Address Line 1

City

State

Zip Code

General History:

Pet's Name *

Upload a photo of your pet

Click or drag a file to this area to upload.

Pet's Breed *

Have you been to our satellite office, Union Pet Hospital, recently?

Yes
No

Pet's Sex

Male
Female
Unknown

How was the bird sexed?

Blood Test
Surgical
Other

How was the bird acquired?

Pet Store
Breeder
Other

Date acquired?

Does the bird have any specific identification? (ex: band, microchip)

Yes
No

Are there any other pets in the house?

Yes
No

If yes, please specify

If the bird is a female, has she ever produced any eggs?

Yes
No

If yes, describe

Housing:

Where is the bird kept?

Indoors
Outdoors
Both

If both, specify percentage of time in each place:

How is the bird housed?

Cage
Aviary
Unconfirmed
Other

Is the bird housed alone?

Yes
No

If no, describe cage mate:

If caged, what type of cage is it?

What type of bedding is used on the bottom of the cage?

How often is the cage cleaned?

List method & frequency of cleaning food/water dishes:

Are there any toys in the cage?

Yes
No

If yes, describe:

Is the bird covered at night?

Yes
No

If yes, how many total hours of darkness?

Diet:

What foods are offered to the bird?

What total percentages? (e.g., 50% seed/50% fresh)

What percentage of these foods are removed from the cage at night?

Are there any supplements offered?

Yes
No

If so, list brands:

Are any treats offered?

Yes
No

If so, what type and how often?

Has there been a recent change in the diet?

Yes
No

If yes, when/why?

How is water offered? (e.g., sipper bottle, bowl)

Reason for Today’s visit:

What signs have you noticed that prompted today’s visit?

How long have you been seeing these signs?

Has the bird been sick previously?

Has the bird ever been seen by any other veterinarian?

Yes
No

If yes, when/why?

Have any tests been performed previously on the bird? Please select all that apply:

Psittacosis
Psittacine Beak & Feather Disease
Polyomavirus
Parasites
Chlamydia
CBC
Chemistry Panel
Other

If other, please describe:

Do you plan on boarding your bird in the future?

Yes
No

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