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ANIMAL PATIENT MEDICAL RECORD—CAT 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 �� FeLV/FIV: �� Neg. �� Pos Dewormer: _____________________ Dosage: ___________ Date: ________ Rabies: �� 1 Year �� 3 Year Date: _________________ (Label) Ext.Parasite: �� Frontline �� Revolution Date: _________________ FVRCP: Date: _________________ (Label) Appendix IV


20028HS
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