AVIAN HISTORY FORM You can download this form in Word format by clicking here and fill it out offline. Please fill out this form to the best of your ability. The more information that you are able to provide us about your bird's behavior, the easier it is to correctly diagnose your bird's behavior problem and provide you with the proper personalized treatment plan. Enter Your Name: Your e-mail Address: YOUR VETERINARIAN First Name: Last Name: Hospital Name: Address: City: State: Telephone: Fax: E-mail: YOUR BIRD 1. What is your bird's name? 2. What is the breed of your bird? 3. Is your bird a male or female? 4. How was it sexed (surgically or blood tested)? 5. Is your bird neutered? YES NO 6. If yes, how old was your bird when he/she was neutered? 7. Why did you neuter your bird? 8. Does your bird have a microchip, tattoo or leg band? 9. If yes, what is the number and when was it put on your bird? 10. Where did you get your bird? 11. How old was your bird when you obtained him/her? 12. For how long have you owned your bird? 13. Did your bird have any previous owner? YES NO 14. If yes, why was he/she given up? 15. Has your bird ever been used for breeding? YES NO 16. If yes, when and with how many mates? 17. Was your bird a hand-fed baby? 18. If yes, how old was your bird when it was weaned? 19. Why did you choose this breed of bird? 20. Why did you choose your individual bird? 21. Has your bird had any medical problems? Yes No 22. If yes, please list what they were and when the occorred? 23. What medications were given? 24. What medications are you giving your bird now? 25. Do you know anything about your bird's parents or relatives? Yes No 26. If yes, did they have any medical problems? What were they? 27. Did they have any behavioral problems? What were they? 28. Does your veterinarian have experience with birds? Yes No 29.Has any blood testing been done for your bird? Please fax any medical records and test results to the NEVBA office @ 781-676-5178. 30. What vaccinations has your bird been given and when? 31. Has your bird been treated for intestinal parasites and when? 32. Are any other pets or humans in the household ill? YOUR HOUSEHOLD 1. Please list all of the people who live in your house with your bird and their ages and their heights. 2. Have you owned pets before? (If yes, what kind?) 3. When did you own the other pets? 4. Did you grow up with pets? (If yes, what kind?) 5. Did any of your other pets have behavior problems? (If yes, what kind?) 6. What happened to your other pets? 7. Please list all of the animals who live in your house: (Name, species (dog, cat, etc.), breed, sex, neuter status, age, when obtained, where obtained from) 8. What kind of home do you have? (house, apartment, town house) 9. How big is your home? How many rooms? PERSONAL BIRD CARE 1. What do you feed your bird? (pellets, seeds, table foods, combination of what) 2. Do you give your bird any vitamins or dietary supplements? Yes No 3. If yes, what type(s)? 4. When do you feed your bird each day? 5. Who feeds your bird? 6. What brand of pelleted food do you give your bird? Does he/she eat it? 7. What table foods will your bird actually eat? 8. When was the last time you changed your bird's diet in any way and how did you change it? 9. Where does your bird's water come from? 10.How often do you change your bird's water? 11. How often do you clean the food and water dishes and what cleaner do you use? 12. How often do you clean the cage and what cleaner do you use? 13. What type of material do you use to cover the bottom of the cage? 14. Can your bird reach the cage bottom material? 15. How often does your bird take bath? 16. How does he/she bathe? YOUR BIRD'S ENVIRONMENT 1. In what type of enclosure do you keep your bird? (cage, aviary with other birds in the same cage or flying free in the home all the time) 2. In what room is the cage kept? 3. In what area of that room is the cage kept? 4. Is your bird allowed in all parts of the house? 5. If not, where is your bird allowed to go? 6. Are your bird's wings timmed? 7. Are there windows in that room that your bird can see through from its cage? 8. Where are other bird cages in the house and which bird resides in which cage? 9. Where does each family member spend most of his/her time? 10. Can your bird see any outside bird feeders from its cage? Yes No 11. Do any animals come around outside your house? (dogs, cats, wild animals) 12. If yes, can your bird see them from its cage? 13. What does your bird do when he/she sees those animals? 14. Do you have any bird play gyms or stands? Yes No 15. If yes, where are they located? 16. What material is the cage made of? If metal, what type of metal? 17. What are the dimensions of the cage (in inches) height x width x depth? 18. How many inches is it from the floor to the top of the cage? 19. How many hours each day is your bird out of its cage? 20. What does your bird do when out of the cage? 21. Does the bird chew on anything inside its cage? What things? 22. Does the bird chew on anything outside of the cage? What things? 23. Does the bird chew on anything with paint on it? Yes No 24. If yes, does the paint have any lead in it? (check the paint can label) 25. What accessories are in the cage? 26. What toys does your bird play with? 27. How often do you change the toys for new ones? 28. How often do you give your bird things to chew up and destroy? 29. How many hours is your bird alone each day? 30. What kind of lighting is near the cage? (fluorescent, incandescent or full spectrum) 31. How many hours is the light turned on each day? 32. How many hours of darkness does your bird get each night? 33. How many hours of the dark period are actually quiet? 34. Do you cover the cage at night? Yes No 35. Do you use a night light for your bird? Yes No 36. Would you please fax us a map of your house including where the windows and doors are and where the cage (s) is/are located. Include your bird's name and your name and fax it to the NEVBA office @ (781) 676-5178. 37. Are you going to fax a house map? Yes No 38. Has your household changed since acquiring your bird? Yes No 38. If yes, what changed: 38A. Death of human in the family? If yes, when? 38B. Death of pet in the family? If yes, when? 38C. Significant family illness? If yes, when? 38D. Divorce ? If yes, when? 38E. Marriage ? If yes, when? 38F. Baby born ? If yes, when? 38G. Child moved away ? If yes, when? 38H. Pet added ? If yes, when? 38I. Family moved ? If yes, when? 38J. Family schedule changed (lost or changed jobs) ? If yes, when? 38K. Other ? If yes, when? 39. What interactions occur between your bird and pets in the household? 40. Please answer the following questions with as much detail as you could: 40A. When does your bird eat? While you are watching? 40B. What does your bird do when each family member comes near him while he is inside his cage? (answer for each family member) 40C. What does your bird do when a family member comes near him when he is outside of the cage? 40D. What does your bird do when someone outside of the family comes near him while he is inside his cage? 40E. What does your bird do when someone outside of the family comes near him when he is outside of his cage? 40F. Does your bird pass stool when someone comes near him? Does this always happen? 40G. What does your bird do if you stare into his eyes? 40H. What does your bird do when a stranger first enters the house? 40I. What does your bird do when you put your hand into the cage? 40J. Does your bird try to get onto your shoulder after you pick him up? 40K. Do you carry your bird around on your shoulder? 40L. Once your bird is on your shoulder what does he do when you try to get him off of your shoulder? How do you get him off? 40M. Does your bird have to be chased around the cage before stepping up onto your hand? 40N. What does your bird do when you handle his feet? 40O. What does your bird do when you try to cut his toenails? 40P. What does your bird do when you want to give him medication? 40Q. What does your bird do when you wrap him/her in a towel? 40R. When does your bird make noise each day (give the approximate times of day and how much it bothers you)? 40S. When your bird makes noise what do you do? Then what does your bird do? 40T. Is anyone else bothered by the amount of noise that your bird makes? 40U. If so, who? Do you avoid grooming or other maintenance work on the bird? 40V. If yes, why? What does your bird do when you open the cage door? 40W. What does your bird do when you try to put him back into his cage? 40X. What does your bird do when you lean over him? 40Y. What does your bird do when you raise your hand? 40Z. What does your bird do when you hug him? 40Z1. Does your bird regurgitate food? Yes No 40Z2. If yes, when? 40Z3. Does your bird build nests? Yes No 40Z4. Does your bird bend over and fan its tail? Yes No 40Z5. Does your bird masterbate? Yes No 40Z6. Are any of your other birds nesting? Yes No THE PROBLEMS 1. What is your bird doing that is a problem to you? 2. Does your bird have any other behavior problems? 3. What happened that made you decide to seek help? 4. When did it happen? 5. What happened before the incident? 6. How did you respond after the incident? 7. How did your bird respond? HISTORY/DEVELOPMENT OF THE PROBLEMS AND CORRECTION ATTEMPTED 1. When was the first time you noticed that your bird had the problem? 2. How old was your bird when you noticed that your bird had this problem? 3. Describe in detail the very first episode of the problem. 4. When was it? 5. What time of day? 6. What happened before the incident? 7. What did you do after it occurred? 8. What did your bird do? 9. Describe in detail another early episode of the problem. 10. When was it? 11. What time of day? 12. What did you do after it occurred? 13. Has the problem been occurring only when you are away from home? Yes No 14. If the problem occurs only when you are home, where are you and where is the bird when it happens? 15. Tell us everything that you have done to try to correct the problem you are having? Include the dates of all attempted corrections, how long you tried and how your bird responded (no better, somewhat better, much better) 16. Has your bird been on any medications for this problem? If yes, what types? When? For how long? was it successful treatment? Did any reactions to the medication occur? DESCRIPTIONS OF RECENT INCIDENTS Describe in detail the most recent episode of the problem: 1. When was it? What time of day? 2. What happened before the incident? 3. What did you do after the episode? 4. How did your bird respond?. Describe in detail the next to last episode of the problem: 5. When was it? What time of day? 6. What happened before the incident? 7. What did you do after the incident? 8. How did your bird respond? Describe in detail the third to the last episode of the problem: 9. When was it? What time of day? 10. What happened before the incident? 11. What did you do after the episode? 12. How did your bird respond?. 13. How often does the problem occur? (times per day, per week, per month) 14. Does the problem happen more often than when it started? If yes, please describe. 15. Was the increase gradual or sudden? 16. Is the problem worse in severity/intensity since it started? If yes, please describe. 17. How often do your bird's other problems occur? (times per day, per week or month) 18. Do the other problems happen more often than when they started? If yes, please describe. 19. Was the increase gradual or sudden? 20. Are these problems worse in severity/intensity since they started? If yes, please describe. 24 HOUR DAY IN THE LIFE OF YOUR BIRD AND YOU Where does your bird sleep at night? Starting with when both of you get up: please indicate when and who feeds your bird, when you or anyone else plays with your bird, when you give your bird attention, when your bird interacts with other animals, when your bird eats other than when he/she first gets food, when your bird is left alone, when you are likely to find evidence of the behavior problem(s) 4-am 5-am 6-am 7-am 8-am 9-am 10-am 11-am 12-pm 1-pm 2-pm 3-pm 4-pm 5-pm 6-pm 7-pm 8-pm 9-pm 10-pm 11-pm 12-am 1-am 2-am 3-am AGGRESSION SCREEN 1. Has your bird ever bitten a person? If yes, who was it? 2. Does your bird bite and then let go or does he/she bite and does not let go? 3. Does your bird scream before attack? 4. Does your bird retreat after biting? 5. Does your bird attack without warning? Describe the incident in detail. 6. When was it? 7. What happened before the incident? 8. What did you do after the incident? 9. How did your bird respond to that? 10. Did the bite break the skin? 11. Did the person require medical treatment? If yes, what kind? (hospital, antibiotics) 12. Was the bite reported? 13. Has your bird ever bitten another animal? If yes, who was it? Describe the incident in detail. 14.When was it? 15. What happened before? 16. What did you do afterward? 17. How did your bird respond to that? 18. Did the bite break the skin? 19. Did it require medical treatment? If yes, what kind? (hospital, antibiotics) 20. Was the bite reported? ATTACHMENT On a scale of 1 to 10, how serious is each problem to you and to each family member? 1 being not at all serious and 10 being the most serious. Main problem: 2. Other problems 3. Have you considered finding a new home for your bird? Why have you not done so? (this question does NOT mean we are recommending this) 4. Have you considered putting your bird to sleep? Why have you not done so? (this question does NOT mean we are recommending this) ALL CLIENTS RECEIVE A FREE LIFETIME SUBSCRIPTION TO OUR ONLINE MAGAZINE "Pet-Lines". Please enter the username and password you would like: Username: Password: Copyright 1999-2006, Petbehaviorproblems.com