Brealey Drive - Avian History Form
Please tell us more about your bird! If you are completing this form for multiple birds in your household, please complete one form in its entirety and in any additional forms answer "same as first bird's name" for any information that is the same between them. Thank you for taking the time to complete this form, it will be very beneficial to us when providing care to your avian companion! If you have any questions regarding this form please call the clinic at 705-741-2322 or send an email to info@brealeydriveanimalclinic.com

**PLEASE NOTE** THIS FORM IS NOT AN APPOINTMENT REQUEST. If you are a new client, please contact the clinic first to set up an account. This form is not monitored daily.
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Client Information
Client Name: *
Phone Number on File: *
Patient Information
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
Bird's Name: *
Species: *
Age: *
Sex: *
Required
Length of time owned: *
Where was your bird acquired?  *
Required
Any additional background information:
Is your bird handled? (YES/NO) If YES, how often? *
Can your bird fly? (wings are NOT clipped)
Clear selection
Is the bird ever taken outside? (YES/NO) If YES, please describe: *
Reason for Visit
If reason for visit is just a general health exam or check up, please state this in "primary reason for visit" and answer "N/A" when necessary.
What is the primary reason for your bird's visit?  *
How long has the concern been present?
Has your bird had any other health problems previously? *
Husbandry
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
Type of cage: *
Size of cage: *
Where is the cage located? *
Cage bedding: *
Decor and furnishings present in cage: *
How often is the cage cleaned? *
What type of products/disinfectants are used when cleaning the cage? *
Does your bird bath? (YES/NO) If YES, how often? *
How does your bird bath? (birdbath, misted, sink, etc.) *
What is your bird's light & dark cycle? *
Does anyone in the household smoke? *
Do you use any aerosolized products in your household? (YES/NO) If YES, what are they? *
Are there any other bird's in the household?  (YES/NO) If YES, how many?
Is your bird housed with another bird?  (YES/NO) If YES, how many? *
How long have they been housed together?
Are there any other pets in the household?  (YES/NO) If YES, what type/how many?
Nutrition
Please answer to the best of your abilities. If unsure of any information please answer "unknown" or "N/A"
What types of foods are eaten by your bird? *
Required
What brand/type of food is your bird eating? (brand/type of pellet mixture, type of fruits/veg, brand/type of treats, etc.) *
What is the amount & frequency in which your bird is eating each type of food? (by number, weight, or approx. volume) *
Do you use any nutritional supplements for your bird? (YES/NO) If YES, please describe (brand, purpose, amount, frequency):  *
How often is their water changed? *
Do you use any water supplements? (YES/NO) If YES, please describe (brand, purpose, amount, frequency): *
Have you noticed any changes in your bird's droppings? (YES/NO) if YES, please describe: *
Is there any additional information you feel we should know about your bird?
Thank you again for taking the time to complete this form. We look forward to seeing you and your avian companion!
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