BIRD CANCER SURVEY FORM

Fill out in as much detail as you can. Your name and mailing address is also appreciated in case we need to contact you with more information. We will also be sending out results to this survey after its completion. All information here will be kept in the strictest of confidence. No names, addresses or phone numbers will be given out or used in any way except to contact you for more information and mail out of results. Thank you for your help with this project.


Name:


Email:


Company:


Mailing Address:



City:
State:
Zip Code:


Was Bird a...
Tame Pet Bird
Breeder with Mate
Breeder without Mate

Was Bird...
Imported
Domestically Bred
Unknown

Was Bird...
Male
Female
Unknown

Name Species of Bird:


Age of Bird if known ( or approx.):


Type and Location of Cancer Diagnosed:


Have you ever lived in a radon area?


My bird drank:


Has Bird Ever Been Medicated?


Has Bird Ever Been Exposed to Mold or Mycotoxins from Hidden Mold?


If so, Describe Meds and Purpose (Illness):


Diet of Bird in Detail:


I fed the bird:


Describe other supplements given (herbs, etc.):


Details of Stressful Periods for Bird:


Describe Housing (Size, Type, Indoors, Outside, etc.):


How Did You Get to Our Site?


if other, be more specific:


Additional Comments: