Name* First Last Pet Name*MicrochipBandIs this bird a pet or is it a breeder?Has this bird produced young or eggs? DescribeWhere did you get this bird from?StorePrivateIndividualOtherWhen did you get your bird?Where is your bird kept?Is your bird kept in a cageFree in the houseIs it an outside aviaryIs it in the houseIs your bird kept with other birds, if so how many?Are there other birds in the same room? Or somewhere else in the house?Are there any sick birds, have any birds already died?What signs have you noticed regarding this bird, this incident? (check all that apply) Diarrhea Blindness vomiting constipation tail bobbing breathing difficulty perching difficulty fainting fluffed feathers drooping or injured wings or legs eye/nostril/ear bleeding injury/bitten by another bird or pet feather picking or feather loss skin bleeding lameness change in personality change in vocalizations change in stool consistency change in appetite excessive water consumption coughing or hoarsenessDescribe any otherHas your bird received any treatment for this problem?Has your bird ever been tested for parrot fever, beak and feather disease, polyomavirus?What toys are available to your bird?What do you use on the bottom of your cage?Do you use sand paper in your cage?Do you use a bird protector?Does your bird ever go outside?What room of the house is your bird in?How often do you change out the paper or litter at the bottom of the cage?How often do you thoroughly clean your bird's cage and what method do yo use to clean it? DescribeHow often do you clean your birds dishes and what do you clean them withHow often do you offer fresh, clean water?Is it offered in a cup or a tube?How many hours of darkness does the bird have each day?How often do you offer fresh food?Describe your birds diet. Does you bird eat pellets? Seeds? Table foods?Does you bird eat the following foods often? (check all that apply) Spinach Romaine Lettuce Collards Fennel Escarole Turnip GreensVegetables (check all that apply) Carrots Broccoli Sweet Potatoes Zucchini Squash and green beansOthers:Fruits (check all that apply) Cantaloupe Honeydew Mango PapayaOthers:Do you give any supplements and if so what kind?How much food does your bird eat a day?Has your bird had any recent diet changes?Have there been any recent changes in your bird environment or in your home?Do you feed high salt foods to your bird?Do you feed your bird any of the following foods? Chocolate Milk Caffeine AvocadoDoes anyone smoke in your house?Do you use any scent products in your home and if so what kind?CommentsThis field is for validation purposes and should be left unchanged.