Email *
Pet's Name *
Species *
Age *
How do you know your bird's gender? *
Length of Time Owned *
Please explain. *
How long has your bird been ill? *
Has the onset of illness been sudden or gradual? *
What signs have you noticed? *
Is your bird eating and drinking? *
Have you noticed any changes in your pet’s voice? *
Are any other pets or humans in the household ill? *
Have you seen another veterinarians for this problem? *
Have any treatments been provided? *
Has there been any response to therapy? *
Has she ever laid eggs? *
When was the last clutch laid? *
How many eggs are usually laid in a clutch? *
Have any malformed or abnormally shelled eggs been produced? *
Is your bird showing any broody behavior now (i.e. shredding paper, hiding in dark places, or regurgitating to a mirror, other birds, or the owner)? *
Describe your bird’s diet. What food items are actually consumed, & in what proportions? *
Is vitamin/mineral supplementation, grit, or cuttlebone provided? *
What is the source of drinking water? *
Size of Cage *
What cage furniture is present? *
What substrate is used? *
How often is the cage cleaned? *
What type of disinfectant is used when cleaning cage? *
Where in the household is the cage located? *
Are any air vents located near the cage? *
Does your bird have a play gym? Where is it located? *
Is the bird ever exposed to natural sunlight? *
Please specify. *
Has your pet been exposed to any “new” birds recently? (this includes newly acquired birds AND bird taken out of the home for bird shows, grooming, boarding, etc.) *
Is there any possible exposure to wild birds? *
Has your pet been exposed to any other strong fumes or sprays? *
How much “one-on-one” attention does your bird receive daily? *
How much time does your pet spend outside of its cage? Is the pet supervised at these times? *
When outside of the cage does the bird have access to houseplants? Has your bird chewed on anything in the household recently? *
How many hours of sleep does your bird get? *
How often? *
How many toys does your bird have? Please describe the toys. *
Where is it located? *
Past Medical History/Problems
Do you have any questions about your bird's behavior?
Current Presenting Problem and Duration of Complaint *
