"*" indicates required fields

HISTORY

Name*

Species*

Age*

Sex*

Male

Female

Unknown

Where did you get your pet?*

How long have you owned your pet?*

How many birds are in your flock?*

Do they get along?*

Do you have a mixed flock (ie multiple types of poultry)*

Does your mixed flock interact directly?*

Has your pet been to a vet before?*

Yes

Where?

Any prior medical concerns?

Do you have any medical records?

Vaccinated for Merrick’s disease?

Is your pet on any medications?

IF YOUR BIRD IS FEMALE

Does she regularly lay eggs?

Yes

How often?

Last egg produced?

Are the eggs being consumed?

Have any malformed or abnormally shelled eggs been produced?

Is your bird showing any broody behavior now (i.e. hiding in dark places, prolonged sitting in next box without moving, feather loss on belly, etc)?

DIET

Describe your bird's diet. What food items are actually consumed, & in what proportions?*

Is your bird on a pelleted diet?*

Yes

Brand?

Amount and frequency?

Poultry seed/scratch?*

Yes

Brand?

Amount and frequency?

Veggies/fruits offered?*

Yes

Types?

Amount and frequency?

Other treats/foods?*

Yes

Types?

Amount and frequency?

What water source is offered?*

How often is it cleaned?*

Any supplements or grit (ie oyster shell or powdered) provided?*

Yes

Type, amount, and frequency?

How is it provided?

LIFESTYLE AND HABITAT

Has your bird been exposed to any “new” birds recently? (this includes newly acquired birds AND bird taken out of the home for bird shows, grooming, boarding, etc.)

Do you quarantine newly acquired birds prior to introducing to the flock?

Yes

How long?

Are they fully separated?

Is there any possible exposure to wild birds?*

Yes

Does your bird live in an outdoor coop?*

Yes

Size?

What is it made of?

Is there coop wire? If so, how far is it buried?

Substrate?

How often is it cleaned, and with what?

Is there a night time coop or nesting box available?

Heat lamps available?

What is the typical coop temperature?

Dust baths available? What material?

ENRICHMENT

Does your bird spend time outside of their coop?*

Yes

How often and for how long?

Do they get put up at night?

Does your pet interact with any other animals? What kind?*

Is your bird routinely handled / interacted with?*

Yes

Who handles them?

Signature*

Date*

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Chicken or Duck

HISTORY

IF YOUR BIRD IS FEMALE

DIET

LIFESTYLE AND HABITAT

ENRICHMENT