Avian New Patient History Form

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Avian New Patient History Form

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Avian New Patient History Form

Completing this form prior to your arrival will permit us to spend additional time reviewing your current concerns as the history will already have been completed. ***For the safety of your pet, our staff, and our other patients, please bring your pet in a carrier. We do have carriers for sale if you do not have one of your own.***

Client Name

First Name:

Last Name:

Email:

Phone:

Address:

City:

State:

Zip:

Patient

Name

Age

Species

Patient History:

How long have you owned this bird?

Where was the bird obtained from?

Is the bird Aviary Bred Wild-Caught

Is the bird Hand-Reared Parent-Reared

Do you have any other birds in the home? Yes No

Does the bird have a tattoo or microchip as a permanent form of identification?

Previous Medical History:

What is the presenting concern today?

Where was the bird obtained from?

Has the patient been ill before? Yes No

Has the bird recently been treated with remedies purchased at a pet shop or supplied by a breeder? Yes No

Is the bird being presented for Second Opinion Referral Other

May we request copies of the pervious medical record? Yes No

Has the patient had previous health screening for potential infectious diseases? Yes No

Husbandry

Is the patient an Aviary Bird Companion Bird Zoological Bird

Is the cage in which the bird was transported, the bird's permanent cage? Yes No

Where is the cage usually located in the home?

Is the bird able to remove itself from view? Yes No

Is the bird permitted to get adequate sleep at night? Yes No

How many hours of darkness does the bird get each day?

Does the bird have access to direct, unfiltered sunlight on a regular basis? Yes No

Does the bird come out of its cage? Yes No Does Not Apply

Are the bird's wings Clipped Free-Flighted

Is the bird exposed to potentially dangerous situations? Yes No

Does the bird interact with other animals or birds? Yes No

Is the bird subject to potential exposure to toxins? Yes No

Diet

What types of food are fed on a regular basis?

If a mix is fed, what percentage of the mix is seed? What percentage is pellets?

Is the primary diet Formulated (Pellets) Seed Based

How much food is being offered and consumed?

Is the food prepared fresh daily? Yes No

Is table food offered? Yes No

Are the dishes cleaned each day? Yes No

Does the bird dunk food into its water dish? Yes No

Does the bird get any treats? Yes No

Are the bird's wings Clipped Free-Flighted

Does the bird receive vitamin and mineral supplements? Yes No

Pediatric Patients:

What hand feeding formula is being used?

Is the formula being prepared according to the manufacturer's recommendations?

Is anything extra being added to the already balanced diet?

What is the temperature of the food when fed?

What are the quantity, frequency and method (syringe, tube, spoon, cup, weaning pellets) of feeding?

Behavior

Does the bird appear to prefer a certain person in the home? Yes No

Does the bird appear to dislike anyone? Yes No

Does the bird act aggressive towards any members of the household? Yes No

How many hours a day does the bird spend alone?

What does the bird see and hear when it is alone?

Does the bird spend any time with other pets? Yes No

Please list any and all history of the bird having; feather destructive behavior, screaming or other unwanted behaviors.

Please Confirm

Thank you for your submission!

***For the safety of your pet, our staff, and our other patients, please bring your pet in a carrier. We do have carriers for sale if you do not have one of your own.***

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CASCADE HOSPITAL FOR ANIMALS

6730 Cascade Road SE.
Grand Rapids, Mich. 49546
616-949-0960

Monday-Thursday 7:30 am – 7 pm
Friday 7:30 am – 6 pm
Saturday 8 am – 5 pm
Sunday 10 am – 5 pm

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BRETON VILLAGE ANIMAL CLINIC

1852 Breton Road SE
Grand Rapids, Mich. 49506
616-988-4980

Monday-Friday 7:30am – 6 pm
Saturday 8 am – 1 pm
Sunday Closed