Avian History FormOwner Contact InformationOwner Name(Required) First Last PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Bird IdentificationBird NameSpeciesSex Male Female UnknownHow was sex determined? DNA (blood/feather) Surgically OtherIf other, describeIdentification Microchip Band TattooList number if knownBird purpose Pet Breeder OtherIf other, describe (bird purpose)Source of bird Store Breeder Adoption/Rescue OtherIf other, describe (source of bird)Date acquired Origin Wild-caught Domestic-bredHas the bird been quarantined? Yes NoQuarantine type Commercial PrivateQuarantine lengthDid any of those birds die or become ill during the quarantine? Yes NoDetails (quarantine illness/death)Present EnvironmentBird is kept in Cage Aviary Free in home Indoors OutdoorsSize and location of bird's enclosureOther birds in same cage or aviary? Yes NoList other birds on premises, past or presentAre any of those birds sick? Yes NoHave any died? Yes NoIf yes, give detailsList other pets in the home or yardList toys available to the birdWhat do you use on the bottom of the cage?Can bird reach it? Yes NoHow often is the substrate changed?Frequency of cage cleaning and products usedMethod and frequency of cleaning food and water receptaclesSleeping habits: hours of darknessSleeping cage condition Covered Uncovered In sleeping cage In regular cageAny activity around cage when bird sleeping (describe)Exposure to UVB Direct sunlight UVB bulbHow many hours (UVB exposure)?Current diet includes Pellets Seeds Fresh foods OtherDiet details / brands of productsVolume of food offered – PelletsVolume of food offered – Fresh foodVolume of food offered – SeedsVolume of food offered – OtherAmount bird consumes – PelletsAmount bird consumes – Fresh foodAmount bird consumes – SeedsAmount bird consumes – OtherHow often is food replaced?How is the bird bathed?How often (bathing)?Medical HistoryPrevious illnesses or injuriesPrevious medicationsAny current medications? Yes NoIf yes, describe (current medications)Vaccination historyWing trimming? Yes NoMethod (wing trimming)Date of last examination Behavioral HistoryAny behavioral issues? Yes NoDescribe (behavioral issues)How long has it been an issue?Any previous or current treatments for behavioral issuesReproductive HistoryIf female, any history of egg laying? Yes NoIf so, when was the last clutch?How often does egg laying occur?How many eggs are produced?Are eggs fertile? Yes NoIf fertile, are offspring viable when hatched? Yes NoDescribe any issues (offspring viability)Current Health StatusReason for visit Wellness exam Illness examIf ill, describe signs and symptomsHow long has problem been occurring?Any treatments tried? Yes NoIf so, what?Mark any of the following symptoms seen Fluffed feathers Anorexia or reduced appetite Regurgitation Loose droppings Sneezing Coughing Tail bobbing Open beak breathing Ocular or nasal discharge Weakness Droopy limb SeizuresCharacteristics of droppings Formed Diarrhea Blood Increased urineStool colorUrate colorOther changes/abnormalitiesAny other concernsCAPTCHAΔ
