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Avian History Form - Page 3
Present Environment (continued)
How many hours of darkness does the bird have each day:
Diet:
Pelleted food brand:
Describe eating habits:
Amount offered to the bird each day:
Amount bird eats each day:
How is water offered:
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:
Chlamydophila
Psittacine beak and feather disease
Polyomavirus
Parasites
Other
Has the bird been seen by any other veterinarian:
If yes, when and why:
What vaccines has the bird been given and the dates given:
Has the bird been dewormed:
What treatment was used:
Additional comments (your opinions regarding this illness/accident:
I have received and read the brochure on chlamydiosis
I was referred to your clinic by:
Please print out this page and bring it with you the day of your appointment.