Calvert Veterinary Center Avian History Form Owner’s Name*Bird’s Name*Date* 1.Patient InformationSpecies*Date of hatch (if known) Date acquired Sex*MaleFemaleUnknownMethod used to determine (ex: blood test)Source (ex: pet store, breeder, previous owner)*Number of previous owners (other than breeder, store)*What states and countries has your bird lived in?*2. EnvironmentWhat room(s) is your bird kept in?*Describe the cage- type, size, perches, toys, other furnishings:*What is on the bottom of the cage?*Are there other birds in the house? If so, what types are they?*List any other pets that you have:*How much time does your bird spend outside the cage?*Is your bird supervised when it is out of the cage?*at all timessometimesnoDo you cover the cage at night or move the bird to a night cage?*List recent changes in the environment, if any:*3. Exposure HistoryHas your bird been exposed to birds other than your own?*YesNoIf yes, which of the following apply?Boardingbird club/showoutdoorswild birdFriend/family’s bird, other birds:*Does anyone in the house smoke?*YesNoIs your bird exposed to kitchen vapors?*YesNoDoes your bird chew on house plants?*YesNoWhen was your house/apartment built?*1978 or priorafter 1978Does your bird chew on painted surfaces (walls or windowsills)?*YesNoDust: is there an unusual amount of dust, or any construction near your home?*YesNoDo you have air filtration?*YesNoPlease list any air fresheners, cleaning products, deodorizers, or insecticides that are used in the same room as your bird.*Please list other possible toxins or irritants:*4. Diet What percent of your bird’s diet consists of the following (please describe what the bird actually eats, not what is offered). The total should add up to 100%:Bird pellets*brand(s):*Seed mixture*brand(s):*Fruit/vegetables*Type(s):*People food*Type(s):*Other:*Type(s):*Treats: types/frequency*Supplements: Multivitamin in:nonewaterfoodBrand/frequency:Mineral:powdercuttleboneblockoyster shell.Is eaten?YesNoIs grit offer?YesNoWater source:*Please describe any recent additions/changes to your bird’s diet:*5. Vaccinations:Please list any vaccine(s) your bird has had and when they were given:*6. Reproductive:Do you plan on breeding this bird?*Yesnopossibly. If your bird has never laid eggs, skip to 7.How many clutches of eggs has your bird laid?does your bird lay continuously?YesNoWhen was the most recent egg?Was the eggnormalthin shelledmisshapen.How many babies have been hatched from your bird?7. Does your bird have any behavioral problems?*Feather pickingScreamingBiting, aggressionFear of peopleOther:8. Previous Conditions, Problems, or Surgeries (list with date, if known):*9. Is your bird here for a:*well-bird check-up, or is itsick?If your bird is sick, please describe the signs and how long the bird has been showing these signs:Is your bird eating normally?*yesnoIf no, describe please:Have you used any medications from a pet store?*yesnoIf yes,list please:Have you notice any of the following:Weight loss?*YesNoWeight gain?*YesNoSneezing?*YesNoDischarge from the eyes or nose?*YesNoIncreased breathing effort?*YesNoDecreased ability to fly or exercise?*YesNoA change in voice?*YesNoA change in droppings?*YesNoAbnormal feathers?*YesNoWeakness in legs or wings?*YesNo10. Has your bird been seen by another veterinarian for any of the current problems?*YesNoIf yes, when?Please list tests performed:Pleas list medications given:11. Is there anything else you would like done today?*Nail trimbeak trimwing trimNo, thanksI have questions about:Other:If your bird is hospitalized, may we have permission to trim the wings? This will make medicating your bird less stressful-both in the hospital and at home.YesNoDid you know that avocado ingestion and fumes from Teflon (and other non-stick surfaces) on cookware, self-cleaning ovens, or heaters can be fatally toxic to pet birds? Please ask us if you need help making your home bird-safe.