ANIMAL PATIENT MEDICAL RECORD—DOG Intake Exam Date: ___________________ Time: _____________________ Clinician(s): ______________ Initials: __________ Breed: ____________________________ Color: _________________________ Neuter: Y / N (circle) Gender: M / F (circle) Age/Birth: ____________________ Est./Act. (circle) Current Weight: _______________ kg/lb . (circle) est./act. (circle) Ear Tag#: _____________ Brand/Tattoo: ______________ Already Chipped? Y / N (circle) Microchip: ________________ EXAM Intake exam Intake Number: ________________________ Deployment: __________________________ Location: _____________________________ T Ears NSF F Eyes NSF F Nose NSF F Mouth NSF F P Abdomen NSF F Heart NSF F Lungs NSF F Hydration NSF F R MuscSkel NSF F Neurol. NSF F Body Condition: Emaciated (1) Very Thin (2) Thin (3) Underweight (4) Ideal (5) Overweight (6) Heavy (7) Obese (8) Grossly Obese (9) Medical Findings: _____________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Assessment/Plan: _____________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Vaccinations: No Vaccination due to Age No Vaccination due to Medical CBC/Chem UA Fecal HWT: Neg. Pos. Rabies: 1 Year 3 Year Date: _________________ (Label) Dewormer: _____________________ Dosage: ___________ Date: ________ Distemper: DHPP DHLPP Date: _________________ (Label) Ext.Parasite: Frontline Revolution Date: _________________ Bordatella: Date: _________________ (Label) Appendix IV
20028HS
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