Poultry New Patient Form | Orchard Mesa Veterinary Hospital

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Client Information

Name*

First

Last

Phone*

History

Pet's Name*

Species*

Age*

Sex*

Male

Female

Unknown

How do you know your bird's gender?*

Where did you get your pet?*

How long have you owned your pet?*

Has your pet been to a vet before?*

Yes

Where?

Any prior medical concerns?

Do you have any medical records?

Is your pet on any medications?

If Your Bird is Female

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 (ie. shredding paper, hiding in dark places, or regurgitating to a mirror, other birds, or the owner)?

Diet

Describe your bird's diet. What food items are actually consumed, & in what proportions?*

Is your pet on a pellet or seed diet?*

Yes

Brand?

Amount and frequency?

Veggies/fruits offered?*

Yes

Types?

Amount and frequency?

Other treats/foods?*

Yes

Types?

Amount and frequency?

What water source is offered?*

How often is it cleaned?*

Any supplements, grit, or cuttlebone provided?*

Yes

Type, amount, and frequency?

How is it provided?

Grooming

Are your bird's wings clipped?*

Yes

How often is it done?

Where?

Does your bird like to bathe or shower?*

Yes

How often?

Lifestyle and Habitat

Has your pet been exposed to any "new" birds recently?*

Yes

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?*

Yes

What kind of cage do they live in?*

Where in the home is it located?*

What is the cage size?*

How many perches?*

What are the perches made of?*

What is the cage lined with?*

How often is the cage cleaned?*

What do you clean the cage with?*

Is there a nest box?*

Yes

Is the cage covered at night?*

Yes

What time?

Enrichment

Does your pet spend time outside of their habitat?*

Yes

How often and for how long?

Indoors or outdoors?

Are they ever allowed to roam unsupervised?

Does your pet have access to toys?*

Yes

What kind?

How often are they changed/cleaned?

Does your pet interact with any other animals? What kind?*

Is your pet routinely handled?*

Yes

How much 'one-on-one' attention do they receive?

Who handles them?

Signature*

Date*

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