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(802) 879 6311
129 Main St, Essex Junction, Vermont 05452
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Anesthesia and Patient Monitoring
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Contact
Dog/Cat Health Questionnaire
Small Mammal/Pocket Pet Health Questionnaire
Backyard Poultry/Waterfowl Health Questionnaire
Please note, this form is to be used for scheduled appointments only
Bird's Name:
*
Client's Name
*
Flock Size: How many birds total are in your flock?
*
New Additions: Have any new birds been added in the last 30 days?
*
Yes
No
Housing: Is the coop
*
Fully Enclosed
Free-range
Mobile/Tractor
Predator Protection: Do the birds have a secure run?
*
Yes
No
Water Source:
*
Well water
City/Town water
Pond/Stream access
Biosecurity: Do you have contact with other poultry/wild birds?
*
Yes
No
Main Diet: please list the brand and type (e.g., Layer Crumble, Chick Starter, Scratch)
*
Supplements
*
Oyster Shell
Grit
Vitamins
Probiotics
Egg status: Is the bird currently laying?
*
Yes
No
If yes, any recent changes in shell quality or frequency?
Treats: What kitchen scraps or snacks are given regulary?
*
Respiratory: Have you noticed any
*
Sneezing
Nasal discharge
Facial Swelling
None of these
Digestive: what does the dropping/manure look like? (e.g., watery, bloody, normal)
*
The Crop: Does the crop feel
*
Hard/Impacted
Squishy/fluid-filled
Empty
Mobility: Is the bird
*
Limping
Tipping over
Staying away from the flock
None of these
External: Any evidence of
*
Mites/Lice
Feather Loss
Scaly legs
None of these
What is the primary concern for today's visit?
*
Δ
Home
New Clients
About
Meet Our Team
Take A Tour
Promotions
Careers
Services
Anesthesia and Patient Monitoring
Health Certificates
Laser Therapy
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Veterinary Dentistry
Wellness and Vaccination Programs
Additional Services
Pet Health
Pet Health Checker
Pet Health Library
Pet Food Recalls
Pet Insurance
Product Recalls
How-To Videos
News
Pet Portal
Pet Records
Refill Requests
Mobile App
Pharmacy
Online Pharmacy
Purina Vet Direct
Hills to Home
Contact
Dog/Cat Health Questionnaire
Small Mammal/Pocket Pet Health Questionnaire
Backyard Poultry/Waterfowl Health Questionnaire
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