5201 Virginia Beach Blvd.
Virginia Beach, VA 23462

(757) 473-0111

Avian History Form

Required fields are marked(*)

Owner's Name:*
First Last
Owner's Email:*

(For copy of this form for your records)
Owner's Phone Number:*
Bird's Name:*
Sex:*
- Male
- Female
- Unknown
Species:*
How was the sex determined?
- Endoscope
- DNA (blood test)
- Other
If "Other" above, please describe:
Identification:*
- Microchip
- Tattoo
- Band
Show Number:
Bird is a:*
- Pet
- Breeder
If breeder (bird has produced young or eggs) please describe:
Date Acquired:
MM slash DD slash YYYY
How was bird acquired?
- Wild Caught
- Domestic Bred
Has the bird been quarantined?
- Commercial
- Private
- No
Length of quarantine?
Other birds kept in same quarantine?
- Yes
- No
Did any of the birds die or become ill while in quarantine?
- Yes
- No
If "Yes" please share details:
Bird is kept in a:*
- Cage
- Aviary
- Bird stand in the house
Wings trimmed?*
- Yes
- No
Other birds in the same cage or aviary?
- Yes
- No
If "Yes" above, please list:
List other birds on the premises, indoors and outdoors:
Are any of these birds sick?
- Yes
- No
Have any of these birds died?
- Yes
- No
If "Yes" above, please give details:
List other pets in the home:*
List toys available to the bird:
What do you use on the bottom of the cage:
Can the bird reach it?
- Yes
- No
Bird is kept:
- Indoors
- Outdoors
If indoors:
- In a separate room
- With family
Frequency of cage cleaning:*
Method/frequency of cleaning food/water receptacle:
How many hours of darkness does the bird have each day:*
Diet: (Check all that apply)*
- Pelleted food
- Seeds
- Combination
- Table foods
Pelleted brand food:
Describe eating habits:
Amount offered to bird each day:
Amount bird eats each day:
How is water offered:
- Cup
- Sipper tube
Recently added food or dietary changes:
What signs have you noticed regarding this bird, this incident: (Check all that apply)*
- Diarrhea
- Vomiting
- Blindness
- Constipation
- Tail-bobbing
- Breathing difficulty
- Perching difficulty
- Fainting
- Fluffed feathers
- Drooping or injured wings or legs
- Eye/ear/nostril bleeding or injury
- Lameness
- Bitten by another bird/pet
- Feather picking/loss
- Skin bleeding
- Coughing/hoarse
- Change in personality
- Change in vocalization
- Change in stool consistency
- Change in appetite
- Excessive water consumption
What other tests has the bird been given: (Check all that apply)
- Chlamydophila
- Psittacine beak and feather disease
- Polyomavirus
- Parasites
- Other
Has the bird been seen by any other veterinarian:
- Yes
- No
If yes, when and why:
What vaccines has the bird been given and the dates given:*
Has the bird been dewormed:*
- Yes
- No
- Unknown
What treatment was used:
Additional comments (your opinions regarding this illness/accident):
I have received and read the brochure on chlamydiosis:*
- Yes
- No
I was referred to your clinic by:
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Email
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5201 Virginia Beach Blvd.,
Virginia Beach, VA 23462
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(757) 473-0111

Avian History Form

Pet Memorial