PET’S NAME: *

OWNER’S NAME: *

DATE:

CHART NUMBER:

Street Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell:

Work:

Email: *

Please circle the types of birds that you currently keep on your premises? *

Chickens
Turkeys
Ducks
Geese

Total number of birds on your premises today? *

How far is your premises to the nearest feed store? *

Commercial poultry operation? *

Urban Farm? *

Does the poultry on your premises have access to (please select all that apply):

The ground outside?
Neighboring premises?

Are your birds

If other, please specify: *

What types of animals have access to the area where your poultry are kept? *

In the last year, have you used veterinarian services for any bird(s) ? *

What Veterinarian? *

Where do you get most of your birds’ medications?

If other suppliers, please specify: *

What medication are your birds currently on?

Medication

Dose

Administration Type

For how long?

What meds have you used in the past? i.e. Coccidiosis prevention, vitamins/probiotics/antibiotics

Medication

Dose

Administration Type

For how long?

Has your poultry flock been vaccinated for the following diseases?

What type of feed do you feed your birds? Include Brand, % of Protein, Pellet/Crumble/Mash for each bird. *

How do you store your feed? *

How quickly do you go through feed? *

Do you give other food other than feed (such as treats)? *

Do you offer oyster shell? *

Do you offer Grit? *

How often do you clean/change the water? *

What is your water source?

City water
Well
Deep Well
Other

If other, please specify: *

If you have well water, when was the last time it was tested for minerals and bacteria? *

In the last 3 months have you had any of the following problems in your flock?

Diarrhea?

Respiratory (nasal/ocular discharge, cough or sneeze, “snicking”, swollen sinuses)?

Neurologic (in-coordination, weakness)?

Wt. loss?

Feed refusal/depression (droopy birds?

Sudden decreased production (egg laying, hatchability, no weight gain)?

Unexplained death?

Other? (specify):

Biosecurity precautions for the feet: Boots or shoes (or boot or shoe covers) solely for the poultry area? *

Do you require dedicated clothing or a change of clothing before entering the poultry area? *

Do you require that hands be washed before handling or after handling the poultry? *

Are visitors or others allowed in the poultry area? *

Are they asked about contact with other birds? *

Where have you obtained your birds?

Date

Seller

City/State

Bird Ages

# Bird

Were new birds usually quarantined from the rest of the flock upon arrival? *

If yes, how many days? *

Did you have dedicated shoes, tools and clothes for the quarantined birds? *

and poultry

Did you take a shower/ change clothes after working with the new birds? *

Were the birds always, sometimes, or never quarantined before they were re-commingled with other birds on your premises? *

Yes
No

If so how long do you isolate the birds? *

Did all, some, or none of the new birds come with a guarantee of health or health certificate? *

Yes
No

In the last year did you sell or give away any of your birds? If YES where? *

If birds were sold and or given away did they go within YOUR county? *

What county? *

If birds were sold and or given away did they go outside your county but within your state? *

If birds were sold and or given away did they go outside your state but within the U.S.? *

Have you visited any locations that had live birds, markets, feed stores, fairs or neighbors? *

Yes
No

If yes, did you take any biosecurity measures before re-entering your own poultry area? *

Yes
No

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Poultry Information Sheet

Supporting the Health of Your Backyard Flock

What medication are your birds currently on?

What meds have you used in the past? i.e. Coccidiosis prevention, vitamins/probiotics/antibiotics

Has your poultry flock been vaccinated for the following diseases?

In the last 3 months have you had any of the following problems in your flock?

Where have you obtained your birds?

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