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Animal & Bird Health Care Center
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Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Geraldine Kaufman
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Home
Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Geraldine Kaufman
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Avian History Form
*
Indicates required field
Name
*
First
Last
Email
*
Pet's Name
*
This bird
*
is a new patient
has been seen before
Species
*
Age (Best Guess) or Date of Birth
*
Where was your bird acquired?
*
Pet Store
Breeder
Other
Environment
How long have you owned your bird?
*
Gender
*
Male
Female
Unknown
How often is your bird handled?
*
Every Day
Ocassionally
never
Does your bird go outside
*
Often
Sometimes
Never
What type of Cage does your bird have?
*
What are the dimensions of the cage
*
Where in the house is the cage located?
*
Do other birds share the cage? How Many?
*
How often is the cage cleaned?
*
Briefly describe the cage (perches, water bowls, bedding...
*
What kind of food do you feed your bird?
*
Pellets
Seed
Fruits
Vegetables
Table Food
Please specify Brands and types of foods along with percentage of diet.
*
Medical History
Do you have previous medical records?
*
Yes
No
If you do have previous records, please have them forwarded to us
Please list any previous medical problems
*
Has your bird ever been tested for:
*
Chlamydophila (Psitticosis)
Polyomavirus
Psittacine Beak and Feather
Avian Bornavirus
Has your bird recently been exposed to other birds? (New bird? Boarding?)
*
Yes
No
Is your Bird groomed regularly?
*
Wings
Beak
Nails
None
Do you bathe your bird?
*
Spray Bottle
Bath/Shower
No
Does your bird have a full spectrum (UVB) bulb
*
Yes
No
Have ther been any changes in your birds environment?
*
Are you concerned with any behavior problems?
*
Have there been any changes in your birds' droppings? Please describe
*
Are there any smokers in the house?
*
Yes
No
If so, Where?
*
If so, by whom?
*
If you do bathe your bird, how often?
*
Have you noticed any of the following?
*
Decreased Appetite
Increased Appetite
Anorexia
Weight Loss
Vomiting/Regurgitation
Difficulty Breathing
Tail Bobbing
Lethargy
Fluffed Feathers
Diarrhea
Stool Caked to vent
Feather Picking
Nasal or Eye Discharge
Thank you for taking the time to fill out this form. Having this information will allow you to get more out of your time with the doctor.
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