The AMC Feather Picking Questionnaire

If you do not yet have an appointment, please call The AMC at (212) 838-7053 to schedule one. Only fill out this form if you have an appointment scheduled with us.
After you have made your appointment and prior to your visit to The AMC, please fill out and submit the following information to us. Doing so will speed your visit, since we will already have your information and your pet’s information on file when you arrive. Fields marked with a red asterisk (*) are required.
Note: The AMC does not release personal information to any third parties.
Patient Information
     
*Client Name *Client Phone # Blue Card #
*Bird Name *Appointment Date  
 
     
The Starting Point
 
1. What type of bird do you own?

2. Where did you obtain your bird?
 Pet Shop
Private Breeder
Other

3. Is your bird?
 Male
Female
Unknown
  3a. Has the sex been confirmed with a laboratory (DNA) test?
 Yes
No
4. How old is your bird?
5. How long have you owned your bird?
6. Are there any other birds in your household?
 Yes
No
(If Yes, where are they located? ie.: same cage, same room, etc.)
7. Do you have any other pets?
 Yes
No
If yes, does the interaction between pets seem:
Stressful
Harmonious
 
Health History
 
1. What does your bird’s diet consist of (INCLUDE TREATS). Check all that apply
Pellets
Nutriberries
Seeds
Fruits
Vegetables		 Cookies/Cake, etc.
Table Foods
Meat
Eggs
Breads
2. What is the major food source?
 Pellets
Seeds
Other
3. Is your bird currently on any medication or vitamin supplements?
Yes
No
(If yes, please list.)
4. Has your bird had any previously diagnosed illness(es)?
Yes
No
(If yes, please list.)
5. Has your bird had any laboratory tests performed?
Yes
No
(If yes, please fax (212-752-2592) or bring to your appointment previous medical records.)
6. What are the primary areas of feather picking on your bird? Check all that apply
Body
Chest
Legs
Wings
 Shoulders
Flank
Head
7. How long has your bird been picking?
1 week
1 month
2-6 months
6-12 months
More than 1 year
Intermittent
  7a. Has it progressed (gotten worse)?
Yes
No
8. Does the bird seem itchy, agitated, or painful?
Yes
No
9. When does the bird seem to pick most? (please check all that apply)
 When you are at work?
When you are at home?
When you are on the phone?
Other, please explain.
10. If you see your bird pick, what is your reaction?
 Scold bird
Give toys
Take him out of the cage
Other, please explain
 
Behavior
 
1. Who is the primary caretaker?
2. Is the bird bonded to
Primary caretaker
Other member of household
No apparent bonding
3. How many hours a day do you spend with your bird?
4. Is your bird dominant with certain members of the household?
Yes
No
5. Does your bird respond to commands when asked?
Yes
No
6. Does your bird perch on family member's shoulders?
 Yes
No
7. Does your bird show any signs of aggression, sexual, or nesting behavior? Please check all that apply
Tearing up papers
Growling
Tail fanning
 Hiding in boxes or cabinets
Increased aggression
More quiet
 
Environment
 
1. What is the brand name of the cage your bird is housed in?
How old is the cage?
2. Where is the cage located? Please be specific. (ie: by windows, doors, etc.)
3. How is the cage set-up? Check all that apply
No toys
1-3 toys
3-5 toys
Wood perch
 Hanging perch
Rope toys
Mirrors
Playgym
4. How many hours of light does your bird get?
5. Do you use Ultraviolet (UV) light?
 Yes
No
6. Have there been any new changes in the household?
Yes
No
(If yes, please explain: New pieces of furniture, houseguests, new pets, new babies, etc.)
7. Have you attempted to make any changes to your bird's environment?
 Yes
No
(If yes, please list.)
8. Are there any smokers in the household?
 Yes
No
9. Is your apartment/house very warm or dry?
 Yes
No
10. Do you use a humidifier?
Yes
No
11. How often do you bathe your bird?
  11a. Do you put additives in your bird’s bath water?
 Yes
No
(If yes, please list.)
  11b. Do you use any sprays sold in the pet store?
 Yes
No
(If yes, please list.)
12. Does your bird chew the walls, paint, mirrors, or anything that you feel may contain lead?
 Yes
No
(If yes, please explain.)

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