Loving Family Vet - AVIAN LIFESTYLE ASSESSMENT

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Email* This field is required.

example@example.com

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Bird’s name* This field is required.

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Origin: Wild caught

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Hand raised

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Species* This field is required.

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Where/who did you obtain the bird from?* This field is required.

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Sex

Age

Length of ownership

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Reason we are seeing your pet today* This field is required.

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Duration of complaint* This field is required.

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Is it getting worse, improving, or staying the same?* This field is required.

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Previous or Current Medications/Vitamins and Minerals* This field is required.

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Any prior health issues we should know about?* This field is required.

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Previous vaccinations

Date given

Previous diagnostics: Blood work

Fecal/Gram Stain

14

Any seed provided?

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

15

Any pelleted foods provided?

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

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Any cooked foods (such as bird street bistro)?

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

17

Fruit

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

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Veggies

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

19

Table Food

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

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Treats

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

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Any supplements given?

BRAND/TYPE

AMOUNT

FREQUENCY FED

#1

#2

#3

#1

#2

#3

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

BRAND/TYPE

AMOUNT

FREQUENCY FED

22

Any change in appetite?* This field is required.

Yes

No

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How

Increased?

Decreased?

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If yes, what percent is the appetite increased/decreased?

How long has this been going on?

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Any recent diet changes/new foods or treats?

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What?

When?

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Drinking normal amounts?* This field is required.

Yes

No

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If no, for how long?

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Any vomiting or regurgitation?

How often?

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Do droppings appear normal in color and amount produced?

Yes

No

31

If no please describe

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Attitude/Personality normal?

Yes

No

33

Please explain

34

Voice Quality normal?

Yes

No

35

Please explain

36

Last molt date

Was it normal?

How long was the molt?

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Using perches?

Type of perches used (wood, plastic, rope, therapeutic/nail trim, heated, etc).

Hiding in cage?

Any odd behavior

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Dimensions of cage

Floor type

Substrate on floor

Toys/Rope inside cage

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Do you have other birds? If so please list gender and species of each.

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Are they in the same enclosure?

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Do you have any other pets in the household?

44

Does anyone in your household smoke

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Please list the date the following services were last done

Nail trim

Beak trim

Wing trim

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Please specify if you would like any of these services performed today