| Date:
|
Recorder: |
| Name
& Address of owner: |
| Telephone: |
Fax: |
| Name
of bird: |
Breed: |
| Age
of bird now: |
Age
at which bird was acquired: |
| Weight:
Color: |
Sex: |
| Origin
of bird: |
| Wild
caught:
Captive bred:
Hand raised: |
Date
of last physical examination:
(Please include copies of any relevant medical
records and/or blood work.) |
| Medical
problems: |
| Any
current medications: |
| Number
of birds in the household: |
| cagemates:
in the same area:
in other rooms: |
| Food: |
| How
long is the bird usually alone:
for ____
hours/day
for ____ days/week
|
Is
the bird normally confined to a cage:
- yes
____ sometimes
____ always
____
|
when or
why:
|
how long:
____ hours/day
|
size of
cage: __________ x __________
x __________
|
equipment
provided in the cage:
|
- no
(please describe housing conditions):
|
| Description
of Problem Behavior: |
| Age
when animal first began showing problem: |
|
Frequency
and Duration / Changes in Pattern / Anything
that seems to trigger the behavior:
|
|
Corrections
or medical therapy applied to date:
|
|
Describe
a typical 24-hour day in your bird’s
life:
|