Client Information
Your Name
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First
Last
Spouse/Other
First
Last
Address
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Street Address
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City
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Virginia
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Armed Forces Americas
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State
ZIP Code
Phone
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Email
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Animal Details
Avian name or identification:
Common or scientific species name:
Date of birth:
MM slash DD slash YYYY
Age:
Sex
Choose One
Male
Female
Spayed/Neutered
Choose One
Yes
No
Unknown
Determined by:
Endoscopy
DNA
Visual
Unknown
Other:
From where did you obtain this bird?
Origin:
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Breeder/Captive bred
Wild caught
Pet store
Imported
Unknown
How long have you had this bird?
Does this bird have a reproductive history?
Choose One
Yes
No
Please give details:
When did your bird last molt?
MM slash DD slash YYYY
How often has your bird been molting?
Please give details:
Does your bird get wing trimmed?
Choose One
Yes
No
Please give details:
Is your bird vaccinated?
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Yes
No
Please give details:
Do you have other birds or pets?
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Yes
No
Please give details:
Have you or your bird had any contact with other birds in the last 30 days?
Choose One
Yes
No
Please give details:
When was the last bird added to your collection?
MM slash DD slash YYYY
Cage Environment
Cage size:
Where is the cage located?
Choose One
Inside
Outside
Please give details
What is the cage made of?
What bedding do you use? Please give details:
What décor and furnishings are present?
Nest box, perches, swings, toys, other
Please give details
Are soaking/bathing facilities provided?
Choose One
Yes
No
Please give details
How often is the cage cleaned?
What cleaning/disinfectant agents are used?
Please give details
What percentage of time does your bird spend inside and outside of its cage?
Is the animal supervised when out of the cage?
Choose One
Yes
No
Please give details
Does your bird have regular exposure to sunlight?
Choose One
Yes
No
Frequency and length of time
Is your bird exposed to full spectrum (UVA and UVB) lighting?
Choose One
Yes
No
Brand?
What is your bird's light/dark cycle?
Are there any smokers in the house?
Choose One
Yes
No
Do you use any aerosolized products?
Choose One
Yes
No
Do you use Teflon pans?
Choose One
Yes
No
Do you use a self cleaning oven?
Choose One
Yes
No
Last self-clean cycle?
MM slash DD slash YYYY
Have there been changes in the bird's environment in the last 3 months?
Choose One
Yes
No
Please give details
Diet
How often do you feed your animal?
Indicate which foods are eaten and in what amounts (by number, weight, or approx.. volume):
Seed mixtures:
Amount & Frequency?
Pellets:
Amount & Frequency?
Fruits and/or vegetables:
Amount & Frequency?
Meat:
Amount & Frequency?
Treats:
Amount & Frequency?
Other:
Amount & Frequency?
Other details?
Do you use any nutritional supplements?
Choose One
Yes
No
What, how much, and how often?
What water supply do you provide?
Choose One
Bottled water
Rain/river
Well water
How is water provided?
How often?
Bowl dripper system, spray.
How often is the water source changed?
Do you use any water supplements?
Choose One
Yes
No
Please give details:
Have you noticed any changes in droppings (fecal material, urine and/or urates)?
Choose One
Yes
No
Please give details:
Have you noticed any changes in feeding or drinking behavior?
Choose One
Yes
No
Please give details:
Reason for Presentation Today
What is the primary complaint or what signs you have noticed?
How long have these problems been present?
What health problems has your bird had previously?
Has your bird received any treatment in the last 30 days?
Choose One
Yes
No
Please give details (what was used, dosage, how often, duration):
Have you noticed any change in your bird's behavior?
Choose One
Yes
No
Please give details
Have any other animals or persons in the household had any illness within the last 30 days?
Choose One
Yes
No
Please give details
General Condition and Functioning
Please provide any changes to the following topics:
Appetite and food intake:
Drinking:
Feces and defecation:
Urine and urination:
Behavior, activity, and locomotion:
Any aspects that need further attention:
Date
(Required)
MM slash DD slash YYYY
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