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? *

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

of your the

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

Yes
No

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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