Avian History Form – Town & Country Animal Hospital

Owner's Name*

First Last

Breed Name*

Pet's Name*

Date of Birth*

Please select your birds sex*

Male
Female
Unknown

How was your birds gender determined?*

DNA
Endoscopy
Visual
Other

If other is selected, please explain:

How long have you had this bird?*

Where did you obtain this bird?*

Do you have other pets?*

Yes
No

If answered yes, please provide details:

Have you or your bird had contact with any other pets in the last 30 days?*

Yes
No

If answered yes, please provide details:

Does this bird have a reproductive history?*

Yes
No

If answered yes, please provide details:

When did your bird last molt?*

How often has your bird been molting?*

Does your bird get his/her wings trimmed?*

Yes
No

If answered yes, please provide details:

When was the last bird added to your collection?*

What is you primary concern? What signs/symptoms have you noticed? How long have these problems been present?*

Does your bird have any prior health issues?*

Yes
No

If answered yes, please provide details:

Has your bird received any treatment within the last 30 days?*

Yes
No

If answered yes, please provide details (medication used, dosage, how often, duration etc. )

Have you noticed any changes in your birds behavior? ( Not eating/drinking, lethargic, etc. )*

Yes
No

If answered yes, please provide details:

Have any other animals or persons in your household had any illness within the last 30 days?

How often do you feed your bird?*

Please indicate what you feed your bird*

Seed Mixture
Pellets
Fruits/vegetable
Meat
Treats
Other
Nutritional Supplements
Water Supplements

Please describe your pets diet/supplements in more detail such as brand, amount (by number, weight or approx. volume/%), type ( like frozen or fresh),etc.*

What water supply do you provide?*

Tap water
Bottled Water
Rain/River water

Have you noticed any changes in your birds droppings (fecal material, urine)?*

Yes
No

If answered yes, please provide details:

In which room of the house is your birds cage located?*

Are bathing/spraying facilities provided?*

Yes
No

What is your birds light/dark cycle?*

What percentage of time does your bird spent inside/outside of its cage?*

Is your bird supervised when out of its cage?*

Yes
No

Does anyone in the household smoke?*

Yes
No

Do you use any aerosolized products?*

Yes
No

Have there been any changes in your birds enviroment in the last 3 months?*

Yes
No

If answered yes, please provide details:

Please add any other comments/information here:

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:00pm
Sunday	Closed

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