$25 OFF NEW CLIENTS’ FIRST SICK OR WELLNESS EXAM*

*Mention this offer when scheduling and at checkout to redeem. Discount applies only to a new client’s first sick or wellness exam and cannot be applied to other services or products. Must be a new client to the hospital. Limit one discount per household. Not redeemable for cash. Offer valid for a limited time only.

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Avian History Form

Complete the avian history form for Landrum Veterinary Hospital in Landrum, SC to help our team provide thorough, personalized care for your bird.

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Caring for Your Feathered Companion Starts Here

A detailed history is essential to provide the most appropriate veterinary care for you animal. Please complete this form as accurately as possible. If there is anything you are unsure about you can discuss it in more depth with the veterinary staff during your appointment.

OWNERS NAME: *

Email *

CHART #:

Avian Name or Identification: *

Common or Scientific Species Name: *

Date of Birth: *

Age: *

Male: *

Female: *

Spayed or Neutered: *

Sex Determined By: *

DNA
Endoscopy
Visual

Origin *

Captive Bred
Wild Caught Import
Unknown

Reproductive history? *

When did your bird last molt? *

How often has you bird been molting? *

Has your bird been vaccinated: *

Does your bird get their wings trimmed? *

Do you have other birds and or pets? *

Have you or your bird had any contact with other birds in the last 30 days? *

Yes
No
Unknown

When was the last bird added to your collection? *

REASON FOR PRESENTATION TODAY

What is the primary complaint or what signs have you noticed? *

How long have these problems been present? *

What health problems has your bird had previously? *

Has your bird received any treatment in the last 30 days? *

Noticed any change in your bird’s behavior?

Have any animals/persons in the household had any illness in the last 30 days? *

DIET

How often do you feed your animal? *

Which foods are eaten by your bird and in what amounts (by number, weight, and/or volume):

Brand

Amount

Seed mixtures:

Brand

Amount

Pellets:

Brand

Amount

Fruits and/or vegetables:

Brand

Amount

Meat (type and amount)

Type?

Amount

Please specify:

Fresh killed
Frozen/thawed
Live prey

Treats:

Brand

Amount

Other foods:

Brand

Amount

Do you use any nutritional supplement? *

What water source do you provide? *

Tap Water
Bottled Water
Rain/river water

Water provided

Bowl
Dripper
Spray

How often is water provided? *

How often is the water changed? *

Do you use water supplements? *

Any changes in feeding or drinking behavior? Please give details: *

Have you noticed any changes in droppings (fecal, material, urine/urates)? Please give details: *

CAGE ENVIRONMENTS

Where is the cage located?

Inside
Outside

What is the cage made of? *

Cage size: *

What kind of bedding are you using? *

Are bathing/spaying facilities provided? *

How often is cage cleaned? *

What cleaning/disinfectant agents used? *

What percentage of time does your bird spend inside: *

What percentage of time does your bird spend outside: *

Is the animal supervised when it is out of the cage? *

Does your bird have regular exposure to sunlight? *

How often? *

Length of time? *

Is your bird exposed to full spectrum (UVA and UVB) lighting?

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

Does anyone in your household smoke? *

Does anyone use any aerosolized products? *

Changes in the bird’s environment in the last 3 months? *

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$25 OFF NEW CLIENTS’ FIRST SICK OR WELLNESS EXAM*

Avian History Form

Caring for Your Feathered Companion Starts Here

REASON FOR PRESENTATION TODAY

DIET

Which foods are eaten by your bird and in what amounts (by number, weight, and/or volume):

Seed mixtures:

Pellets:

Fruits and/or vegetables:

Meat (type and amount)

Treats:

Other foods:

CAGE ENVIRONMENTS

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