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Personal
*Owner's Name
*Phone
*Address
*Pet's Name
Species
Age
Sex (M/F/Unknown)
How was the bird's sex determined? (Surgically/DNA/Other?)
Identification? (Tattoo, Microchip, Band)
Is your bird a pet or breeder? If it has produced young or eggs please describe.

Source of Bird
Where did you get your bird? (Store, Private Party, Breeder, Other)
Date Acquired
Wild Caught or Domestic Bred?
Has the bird been quarantined? If so please describe (Commercial, Private, length of time)
Was the bird isolated prior to introduction to present location? If so, please describe (length of isolation, other birds in isolation area, any bird deaths during isolation period)

Present Environment
Where is the bird kept? (Cage, Aviary, Free in House, wings clipped)
Are there any other birds in the home/aviary?
Are any other birds sick? If so have any died? Please describe
List any toys available to bird
What is used on the bottom of the cage?
List other pets in the home
Please describe the frequency and method of cage cleaning
Please describe the frequency and method of cleaning food/water dishes
How many hours of darkness does the bird have each day?

Diet
Describe diet. (Food type; pelleted, seed, table food, combination, brand, ect)
Describe the amount of food offered and eaten each day
How is water offered? (Cup, tube)
Any recently added foods or dietary changes?

Tests
Psittacosis (Y/N)
Beak and Feather Disease (Y/N)
Polyomavirus Bornavirus (Y/N)
Fecal (Y/N)
Blood Count (CBC) (Y/N)
Blood Chemistry (Y/N)
X-Rays (Y/N)
Culture (Y/N)
Other

Vaccines
Please describe any vaccines the bird has been given and date given:
Has the brid been seen by another veterinarian? If so please describe when and why
Is the bird currently on or ever been on medication? If so please describe

Additional Comments
Any additional comments
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