Bird Questionnaire

CLIENT INFORMATION

How long has your pet had these symptoms?

What health problems has your bird had previously? (if any) *

Any changes in eating or drinking? *

Yes
No

Have you noticed any changes in droppings (fecal material, urine and urates)? If yes, please describe. *

Has your bird received any treatment in the last 30 days? If yes, please give details (what was used, dosage, how often, duration): *

DIET

This section is VERY important. Be as accurate as possible. Indicate which foods are eaten and in what amounts (by number, weight, or percentage of the total amount eaten).

PELLETS | Brand and amount *

SEED MIXTURES | Brand and amount *

FRUITS and/or VEGETABLES | Type and amount *

TREATS | Brand and amount *

Do you use any nutritional supplements? If yes, what, how much and how often?

ENVIRONMENT

What percentage of time does your bird spend INSIDE of its cage? *

What percentage of time does your bird spend OUTSIDE of its cage? *

What is your bird's light/dark cycle? *

This is the amount of hours in the dark and in light, either artificially (lights out and in a dark cage or room, or following natural light cycles.)

Any additional comments or questions

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Bird Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

REASON FOR VISIT

DIET

ENVIRONMENT