Poultry History Form

Please complete the form below to submit the Poultry History Form online. You can also click the button below to download and print the form.

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Owner’s Name *

First

Last

Email *

Pet’s name *

Species *

Age *

Sex *

Female
Male

How long have you had this bird? *

Does your bird lay eggs? *

If yes, how frequent does she lay? *

Does your bird lay year round? *

Do you know when she last laid?

Is your bird vaccinated for Marek’s? *

Yes
No
Unknown

Any other vaccines *

How many birds are in this flock? *

Where is this bird in the “pecking order?” *

List any other pets you have beside this flock:

When was the last bird added to this flock? *

Reason for presentation today

What is the primary complaint or what signs have you noticed? How long have these problems been present? *

Describe any health problems previously found in this flock: *

Has your bird received any treatment in the last 30 days? *

If yes, please give details (what was used, dosage, how often, duration): *

Are any other birds in the flock showing similar symptoms? *

Have any other animals or persons in the household had any illness in the last 30 days? *

Diet

List everything fed to the flock (Include brand names of commercial foods, human foods/scraps, etc.)

Describe how the food is stored

Do you use any supplements or medications? *

If yes describe type, frequency, dose and type of delivery (i.e. via water, food, etc)? *

Coop/Environment

Describe your coop layout (size, materials, etc) *

Describe outdoor space (caged vs free roam) *

Describe cleaning procedures *

Describe biosecurity protocols *

Has your coop ever been tested for lead? *

Has your soil ever been tested for lead? *

Results if applicable *

What water sources are available to your flock? *

Bowls
Kiddie pool
Third Choice
Drip system
Lake/pond
Other

If other, please explain *

How often do you clean water source? *

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