Avian (Bird) History Form Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear understanding of your pet's current health status, we need you to fill out the history form below.Today's date Species:Parakeet (Budgie)CockatielCanaryFinchLovebirdAfrican GreyAmazon ParrotCockatooMacawConureotherIs this your first bird?YesNoHatch date Actual DateEstimatedDate AcquiredWhere from?Form of IdentificationTattooMicrochipBandNoneotherGenderMaleFemaleUnsureHow Determined?DNASurgicalLaid EggsDimorphicPlease list other pets you have at home and if they have any current illness:ENVIRONMENT Indicate Height, Width & Length Are there any other birds sharing this cage or in direct contact?YesNoAre there any smokers in the house?YesNoDoes your bird spend time out of the cage?YesNo Is your bird ever unsupervised outside of the cage?YesNo NUTRITIONDiet ProvidedWhat the bird actually eats:Supplements provided:Has your bird been eating normally?YesNo MEDICAL HISTORYPlease list any medical problems:Current treatments or supplements:Please list any previous medical problems:Have you noticed changes in:StoolAppetiteThirstMobilityVocalization Have you noticed:VomitingTail BobbingBreathing DifficultyFluffed FeathersDrooping WingsFeather PickingPerching ProblemsCopy of Describe when and duration:Former Vet VisitsYesNo Date of last visit: Records RequestedYesNoReceived?YesNoPrevious Lab Tests / Diagnostics:YesNoDate of last testing:Tests Conducted:Complete Blood CountChemistry ProfileBile AcidCultureGram StainPsittacosisPolyomavirusPsittacine Beak and Feather DiseaseOther Tests:Abnormal Results:Results Requested:YesNoSent to Clinic?YesNoYour Signature To the best of my knowledge, the information provided above and on the patient history form is accurate and complete. I authorize you to contact my referring veterinarian if clarification of medical history is needed or to acquire previous veterinary records, I understand that payment is due at the time services are rendered. I agree to pay all charges at the time my pet is discharged.Data Privacy and Consent:I agree to the terms of service