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Patient History Form (Avian)
Patient Information
Patient Name
First
Breed
Age
Sex
M
MN
F
FS
Chief Complaint/Reason for Visit
Ongoing Conditions
Additional Concerns
Current Medications
Known Allergies
Current Diet
Pellets
Seeds
Table Food
Treats
Other
If other, please specify
How Acquired Pet
Hand Reared?
Yes
No
Towel Trained?
Yes
No
Caging
Substrate
Time out of Cage?
Date of Last Bath/Grooming
Date Format: MM slash DD slash YYYY
Health Information
Cardiovascular/Respiratory
Coughing
Yes
No
Anything produced from cough?
Sneezing
Yes
No
Any discharge/describe
Wheezing
Yes
No
Difficulty Breathing (Tail bob)
Yes
No
Exercise intolerance
Yes
No
Fainting or Weakness
Yes
No
Retching or Gagging
Yes
No
Unusual Noises/Swelling
Yes
No
Skin
Itching
Yes
No
Location
Feather loss
Yes
No
Location
Plucking/Pulling
Yes
No
Dandruff or Dry skin
Yes
No
Odor or pigment changes?
Yes
No
Masses or Swellings?
Yes
No
If yes, please describe
When is it worse?
Seasonal
Continuous
Which Season?
Do medications help?
Yes
No
Temporary
GI/Digestive
Possibility of Foreign Body Ingestion
Yes
No
Vomiting or regurgitation
Frequency
Describe
Diarrhea or Constipation
Less
Normal
Color change
Normal timing
Watery
Blood
Dry
More
Increased urates
Yes
No
Swelling in abdomen
Yes
No
Describe Feces
Any known triggers
How long?
Ears
Shaking Head or scratching
Yes
No
Discharge/Odor
Yes
No
If yes, please specify
Swelling
Yes
No
Pain
Yes
No
Heat
Yes
No
Parasites
Yes
No
Hearing Loss
Yes
No
Which ear
Left
Right
Both
Eyes/Head/Neck
Swelling or asymmetry
Yes
No
Nares or Choanal Discharge
Yes
No
If yes, please describe
Red eye or color change
Yes
No
Describe
Vision Changes
Yes
No
Pain (rubbing or avoiding light)
Yes
No
Allergies
Yes
No
Smoking or Candles around pet
Yes
No
How long has this been noticed
Which eye affected
Left
Right
Both
Musculoskeletal
Difficulty Rising/Jumping/Climbing
Yes
No
Stumbling or Falling
Yes
No
Shaking or Tremors
Yes
No
Bottom of Cage
Yes
No
Non Weight bearing
Yes
No
Drooping Wing
Yes
No
Weak Grip
Yes
No
Ongoing issues
Yes
No
If yes, please describe
History of trauma?
Yes
No
If yes, please describe
Onset?
Legs affected
RW
LW
RH
LH
Neurological
Head Tilt
Yes
No
Change in attitude or behaviors
Yes
No
If yes, please describe
Seizures
Yes
No
if yes, when was the last seizure?
How many in a month?
Length of Seizure
Medications
Memory loss/confusion
Yes
No
Sudden Blindness or Deafness
Yes
No
Muscle or Grip weakness
Yes
No
If yes please tell us when it started
Oral / Dental
Odor
Yes
No
Vocal Change
Yes
No
Growths or Masses
Yes
No
Unexplained swelling
Yes
No
Painful
Yes
No
Difficulty swallowing/eating
Yes
No
Dropping Food
Yes
No
Break Overgrowth or abnormalities
Yes
No
Please describe concerns
Reproductive / Cloaca
DNA sexed
Yes
No
Eggs laid
Yes
No
Previous Clutches
Date
Date Format: MM slash DD slash YYYY
Number of litters
Please enter a number from
0
to
100
.
Problems with laying?
Behavioural Issues?
Other concerns
Masses or Growths
Location
Yes
No
If yes, please describe
When did it appear?
History of cancer?
Yes
No
If yes, please describe
Mass growth
Yes
No
Ulceration or bleeding
Yes
No
Bothering pet
Yes
No
Mobile
Yes
No
Diameter of mass
Yes
No
Soft
Yes
No
Hard
Yes
No
Discharge
Yes
No
If yes, please describe
Cage
Location
If yes, please describe
Substrate
If yes, please describe
Draft Exposures
If yes, please describe
Toys
If yes, please describe
Water Source
If yes, please describe
Other Birds
Yes
No
Cage Size
Perches of varying size
Other
Ongoing History
Pertinent Medical History that wasn't covered
Any other history you want us to know?
Today's Date
*
Date Format: MM slash DD slash YYYY
Typed Signature
*
Signature
Consent
*
I agree to the privacy policy.
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New Clients
New Client Registration Form
Patient History Forms
About Us
Services
Patient Resources
Online Pharmacy
Follow Up Survey
Forms
Payment Options
Pet Health
Interactive Animal
Breed Info
Pet Health Library
Videos
Pet Health Checker
Pet Insurance
News
Contact Us
Prescription Refill and Food Order Request Form
Curbside Care Form
