Questionnaire for Bird Owners
Owner Name: ______
Date: ______
Bird’s Name ______/ Type of Bird (Species) ______Color(s) ______/ Age ______
Sex (Circle one) Male Female Unknown
Primary Reason for Today’s Appointment ______
If this is your bird’s first visit to our hospital, please take a few minutes to answer this questionnaire about your bird. This information will help the veterinarian to more effectively and efficiently treat your bird’s health needs. Thanks in advance for your thoughtful answers!
Does your bird have any current health problems? Yes No
(If yes, please circle all that apply)
Sleeping a lot
Vomiting
Runny droppings
Sneezing
Breathes with his/her mouth open
Over grown beak
Pulls our his/her feathers
Other (please explain) ______
How long have you owned this bird? ______
Who is the primary caretaker of the bird? ______
Does your bird come out of his/her cage? Yes No
If yes, how often and for how long? ______
If no, why not? ______
What have you been feeding your bird? (Circle all that apply)
Seed (What kind? ______)
Pellets (What kind? ______)
Vegetables (What kind? ______)
Fruit (What kind? ______)
Other “people food” (What kind? ______)
Treats (What kind? ______)
Do you keep your bird’s wings clipped? Yes No
If yes, who clips his/her wings? ______How often? ______
Do you cover his/her cage at night? Yes No
How many hours per night is the cage covered? ______
Does your bird live alone or with other birds? ______
Who are his/her cage mates? ______
Please list the toys you keep in your bird’s cage: (Just do your best ☺)
1- ______6- ______
2- ______7- ______
3- ______8- ______
4- ______9- ______
5- ______10- ______
Are there more than 10 toys in the cage? Yes No (If yes, how many? ______)
PREVIOUS MEDICAL HISTORY
Has this bird ever been seen by a veterinarian? Yes No
If yes, whom? ______
In what town/state does this veterinarian practice? ______
What name would your bird’s medical records be under? ______
When was his/her last veterinary visit? ______
Has this bird been sexed using DNA testing? (Circle one) Yes No I don’t know
If not, are you interested in talking about DNA sexing today? (Circle one) Yes No Maybe
Has your bird been tested for any of the following avian diseases? (Circle one)
Polyoma virus Never tested Negative Positive
Psittacine Beak and Feather Disease Never tested Negative Positive
Psittacosis (Chlamydiosis) Never tested Negative Positive
If your bird has never been tested for any of the above diseases, are you interested in talking to the veterinarian today about the diseases and whether or not testing is appropriate for your bird?
(Circle one) Yes No Maybe
Has your bird ever…
been put under anesthesia? (Circle one) Yes No I don’t know
had surgery? (Circle one) Yes No I don’t know
been treated for a serious illness? (Circle one) Yes No I don’t know
If you answered yes to any of these questions, please explain:
______
______
______
Is there anything else that you think we should know about your bird? ______
Thank you for filling out this questionnaire!
Please let the front desk staff know that you are finished and the veterinarian will be with you and your bird shortly.