Lucks Lane Veterinary Clinic

Avian History Form

Form

First Name(required)

Last Name(required)

Pet's Name or Identification(required)

Species(required)

Age(required) *

Sex of Pet(required) *

Origin(required) *

How sex was confirmed(required) *

How long have you owned?(required) *

Yes

What is the primary reason you have brought your bird here today?(required)

When did the problem or signs begin?(required)

Have any medications been given or treatments been attempted?(required)

Have there been health problems in the past?(required)

Do you own other birds or pets? If so, please describe the number of animal and the species housed.(

Yes

If yes, when:

Yes

What is the cage type?(required)

What is the cage size?(required)

The cage is made of?(required)

List all cage furniture, toys, and accessories:(required)

Describe the number and type of perches:(required)

What cleaning methods are used?(required)

What is the frequency of cleaning?(required)

What is the temperature of the house and room where the bird lives?(required)

Are there heat sources?(required)

What is the humidity?(required)

What light sources are provided?(required)

Yes

How old are the full-spectrum lights? How often are they changed?

How many hours of light are provided daily? How many hours of dark per day?

Yes

I don't know

Do you have electric or gas heat?(required) *

Is your bird exposed to any smoke (tobacco), essential oils, kitchen oils, or others?(required)

Have there been any changes in the environment (new house, pet, people, cage location, etc)?(require

What is the diet? (What is offered and what is eaten?) Include brand names, and be as specific as po

Where are the food items obtained?(required)

Please describe the type and frequency of supplimentation.(required)

What is the frequency and timing of feeding?(required)

When did the animal last eat?(required)

Where is food purchased?(required)

How often is the animal handled?(required)

Yes

If yes, how often and for how long?

Yes

Does your bird have any behavior or aggression issues?(required)

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