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Niles Animal Hospital & Bird Medical Center

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7278 North Milwaukee
Niles, IL
60714

Ph: 847-647-9325
Fax: 847-647-8498
E: info@nilesanimalhospital.com

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Avian History Form

Home » Forms » Avian History Form

Avian History Form

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Step 1 of 6

16%

Personal
Owner's Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Pet's Name
Species
Age
Sex
- Male
- Female
- Unknown
How was the bird's sex determined?
- Surgically
- DNA (blood)
- Other
If other, please state:
Identification
- Tattoo
- Microchip
- Band
Bird is:
- A pet
- A breeder (has produced young or eggs)
Describe

Source of Bird
- Store
- Private Party
- Breeder
- Other
If other, please state:
Date acquired
Date Format: MM slash DD slash YYYY
- Wild Caught
- Domestic Bred
Has the bird been quarantined?
- Commercial
- Private
- Length of Time
State length of time
Was the bird isolated prior to introduction to present location?
Length of isolation (days)
Other bird species in isolation area
If known, any bird deaths during isolation period?

Present Environment
Bird is kept in:
- Cage
- Aviary
Wings Clipped?
- Yes
- No
Other birds in the same cage or aviary?
- Yes
- No
Are any other birds sick? Have any died? If yes, give details.
List toys available to bird
What is used on the bottom of the cage?
Bird is kept:
- Indoors
- Outdoors
- In a separate room
- With family
List other birds in the immediate vicinity
List other birds in the home/aviary
Frequency of cage cleaning
Method of cleaning
How many hours of darkness does the bird have each day?

Diet
- Pelleted Food Only
- Seed
- Table Food
- Combination
Please suppy names of above chosen foods
Amount offered each day
Amount eaten each day
How is water offered?
- Cup
- Tube
Recently added foods or dietary changes

This Visit
What prompted you to bring in the bird?
Have you noticed (check all that apply)
- Diarrhea
- Blindness
- Vomiting
- Constipation
- Tail-Bobbing
- Breathing Difficulty
- Perching Difficulty
- Fainting
- Sitting Fluffed Up
- Drooping Wing
- Bleeding
- Feather Picking
- Lameness
- Change in Personality
- Change in Vocalizations
- Change in Appetite
- Change in Stool Consistancy
- Excessive Water Consumption
- Other
If other, please specify

Tests
Vaccines the bird has been given and date given
Has the bird been seen by another veterinarian? When? Why?
Is the bird currently on medication?
Has the bird been on medication? When?
Which medications had been used?
Additional Comments:

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Avian History Form
Client Information Form
Client Information Update Form
Make an Appointment
New Canine Vaccination History
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Location Hours

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 2:00pm
Sunday	Closed

*CLOSED Mon-Fri 12 to 2pm

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