Bird Medical Intake Form

Owner's Name:

Patient's Name:

Reason for Visit:

Additional Concerns:

Symptoms:

Duration of Symptoms:

Prior History of Medical Issues:

Puffed Up and/or in Bottom of Cage:

Behavioral Changes:

Eating/Drinking?

Urinating/Defecating?

Vomiting?

Current Diet Including Any Supplements:

What Type of Cage & Where is it Located?

What is the Substrate (what you line the bottom of the cage with) of the Cage?

Bathing: How? Frequency?

Hours of Sleep at Night?

Direct Sunlight Weekly that is NOT Filtered by a Window?

How did you Acquire the Bird?

How Long Have you Had the Bird?

Has s/he had a Negative Chlamydia Test?

How Many Other Animals in the Home?