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Custom Template Library
A collection of templates you can copy, paste and modify when creating a custom template for Talkatoo Notes.
Glossary
Emergency SOAP
Emergency Triage
Emergency Pet Poison Control
Support Staff History and Vitals
Telemedicine SOAP
Surgery Consultation Report (Orthopedic)
Surgery Intake and Anesthesia Report
Neurology Consultation Report
Cardiology Consultation report/Echo report
Ophthalmology Consult Report
Rehabilitation SOAP
Reproduction Puppy/Kitten Litter
Palliative Care/ Euthanasia Appointment
Chiropractic
Acupuncture SOAP
Necropsy Report
Vet to Vet Daily Rounds
Radiograph Report (General Practice)
Radiograph Report (Specialty)
CT Report
MRI Report
Ultrasound Report
AFAST/TFAST Ultrasound Report
Prescrotal Neuter Surgery Report
Physical Therapy
Lameness Exam
Acupuncture/Chiropractic Exam
Pre-Purchase exam
Foal Exam
Dentistry
Dental Exam/ Procedure Report
Castration Report
Farm Animal SOAP
Ruminant Herd Health
Reptile SOAP
Rabbit and Rodents SOAP
How to use
Here is a curated collection of Custom Note Templates that we and our users have created for you to use as is, or to modify as needed. You can also use them for ideas or inspiration on how to lay out your own note.
We have purposefully left off the optional Additional formatting options, as these vary so much between users. For more information on formatting, you can click here.
To use one of these notes:
- Open https://app.talkatoo.com/settings/custom-templates
- Click + Create a Custom Template > Write your own template
- Enter a title.
- Copy the text from the note you want to use below, then paste it into the main box
- {Optional} Add any formatting options by clicking Show Advanced Prompting below the main box
- Click Save Changes
As many of these templates are from our users, be sure to read them carefully to ensure there are no mistakes or changes you need to make.
As always, the results of these notes are generated using AI, so it is important to read the results carefully to ensure they are accurate, complete and correct.
General Templates
Emergency SOAP
SUBJECTIVE:
Presenting Complaint:
Rx:
History:
OBJECTIVE:
Vitals:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: Pink and moist
Capillary Refill Time: <2 Sec
BCS:
PHYSICAL EXAM
Attitude/Behavior: Within normal limits
Hydration: Euhydrated
Nose/Throat: Within normal limits
Eyes: Within normal limits
Ears: Within Normal Limits
Mouth/Teeth: Within normal limits
Heart/Blood Vessels: Within normal limits.
Lungs/Airways: Within normal limits
Abdomen: Within normal limits.
Gastrointestinal System: Within normal limits. 4 quadrants auscultate normally.
Coat/Skin/Hooves: Within Normal Limits
Lymph Nodes: Within normal limits
Musculoskeletal: Within Normal Limits
Nervous System: Within normal limits
Urinary/Genitals: Within normal limits
Other:
ASSESSMENT:
Problem List:
Differential Diagnoses:
Prognosis:
PLAN:
Emergency Triage
Presenting Complaint:
Summary of History:
Time of presentation:
Time of triage:
Vitals:
Attitude: BAR
Wt:
T: , P: , R:
MM: Pink. CRT <2sec
Hydration: Euhydrated
Pain Score:
Other Physical Exam Notes:
Triage Comments:
Point of Care Diagnostic Tests:
Emergency Pet Poison Control
CASE INFORMATION:
Service Contacted:
DVM Consulted With:
Case Number:
Existing Case Call Back Number:
Pet’s Name:
Pet’s Weight:
INGESTION INFORMATION
Substance(s) Ingested:
Date and Time of Exposure:
Clinical Concerns:
PLAN
Recommended Treatment Plan:
Anticipated Duration of Clinical Signs:
Required Follow-Up:
Support Staff History and Vitals
SUBJECTIVE:
History Collected By:
Presenting Complaint:
Historical Conditions:
Diet/Appetite:
Drinking/Urination:
V/D/C/S:
Skin & Coat:
Mobility:
Current Medications:
Lifestyle Risk Factors:
Travel History:
Additional Information:
OBJECTIVE:
Wt:
T: Not taken
P:
R:
MM: pink/moist. CRT < 2sec.
Telemedicine SOAP
SUBJECTIVE:
Signalment:
Presenting Complaint:
History:
Diet:
Drinking/Urination:
V/D/C/S:
Medications:
Lifestyle Risk Factors:
Other:
OBJECTIVE (telemedicine exam):
The following documents a remote exam for a telemedicine call, and all observations were made remotely via video, photo or through collaboration with the client.
Vitals:
Temp: Not performed.
Heart Rate: Not performed.
Respiratory Rate: Normal, not performed.
Mentation: BAR
Wt:
BCS: Not assessed
MM: Not assessed
Hydration: Not assessed
Eyes: Not assessed
Ears: Not assessed
Nose: Not assessed
Throat: Not assessed
Oral: Not assessed
Cardiovascular: Not assessed
Respiratory: Not assessed
Abdominal: Not assessed
Lymph Nodes: Not assessed
Integumentary: Not assessed
Neurologic: Not assessed
Musculoskeletal: Not assessed
Urogenital: Not assessed
Rectal: Not assessed
ASSESSMENT:
Problem List:
Differential Diagnoses:
PLAN:
Diagnostics Recommended:
Treatments/Procedures Recommended:
Diagnostics Performed:
Treatments/Medications Performed:
Next Steps:
Surgery Consultation Report (Orthopedic)
Subjective
Presenting Concerns:
History:
Current Medications:
Objective
General Appearance: BAR, responsive to stimuli, appropriate mentation unless otherwise noted
Body Condition:
Body Weight:
Ideal Body Weight:
FAS Score (0-5):
Left Thoracic Limb:
Right Thoracic Limb:
Left Pelvic Limb:
Right Pelvic Limb:
Radiography
- Ultrasound:
- X-Ray:
- Other:
ASSESSMENT
Problem List:
Assessment:
Plan:
- Owner Discussion:
- Recommendations:
- Treatment:
Surgery Intake and Anesthesia Report
Tech Name:
INTAKE
Owner confirmed patient was fasted overnight: Yes/No
Any c/s/v/d or other concerns since last visit: Yes/No
Discussed surgical and anesthetic risks and protocols: Yes/No
Signed consent for:
Declined:
Owner can be reached at # today.
Will call at # for update and to arrange pick up time.
OBJETIVE
Mentation: BAR
BCS: /9
T:
P:
R:
Thoracic Ausculation: NAF
MM: pink, moist, CRT <2 sec
Hydration : normal
Assessment:
Medications:
Premedicated with:
Drug 1 Name Drug 1 Concentration mg/ml : ml
Drug 2 Name Drug 2 Concentration mg/ml : ml
Drug 3 Name Drug 3 Concentration mg/ml : ml
Mixed and given IM injection location at : hr
Placed gauge g catheter in catheter location; connected to fluid type at fluid rate ml/hr intra-op.
Induction Drug 1 Name Induction Drug 1 Concentration mg/ml : ml
Induction Drug 2 Name Induction Drug 2 Concentration mg/ml : ml
Both given IV at time given; total volume administered: ml
Local Anesthetic Name Concentration mg/ml: ml location
Inhalant Agent Name: %
Anesthetic time: Start-End or duration
Surgical time: Start-End or duration
Extubated at:
Post-op Temperature: C/F
Post-op Fluid Rate: ml/hr
Neurology Consultation Report
Subjective
Presenting Concerns:
History:
Current Medications:
Objective
General Appearance: BAR, responsive to stimuli, appropriate mentation unless otherwise noted
Body Condition:
Body Weight:
Ideal Body Weight:
FAS Score (0-5):
Mentation:
Gait/Posture:
Nociception:
Muscle Atrophy:
Cranial Nerves:
Proprioception/Postural Reactions:
Segmental Reflexes/Muscle Tone:
Palpation:
Neuroanatomical Localization:
Assessment:
Plan:
Cardiology Consultation report/Echo report
Subjective:
Diagnosis:
Preexisting Conditions
Recommendations:
Medications
Diet
Exercise
Anesthesia
Follow Up
Reason for Presentation:
Name presented to Practice Name for an evaluation of .
Objective:
General attitude: Alert and responsive
Weight:
Mucous membranes:
Cardiac auscultation
Heart murmur:
Other heart sounds: None
Rate and rhythm:
Respiratory character: Normal effort
Respiratory rate:
Lung auscultation:
Femoral pulses:
Abdominal palpation: No signs of fluid accumulation
Other: None
DIAGNOSTICS
ADDITIONAL INFORMATION
ECHOCARDIOGRAM REPORT
Findings
ECG rhythm:
Study quality: This was a technically good study.
Left Ventricle: The left ventricle is normal in size.
Right Ventricle: The right ventricle is normal in size.
Left Atrium: The left atrial size is normal.
Right Atrium: The right atrial size is normal.
ASD/VSD: No evidence of interatrial communication by color flow Doppler analysis. Interatrial and interventricular septum intact.
Aortic Valve: The aortic valve is trileaflet, and appears structurally normal.
Mitral Valve: The mitral valve appears structurally normal.
Tricuspid Valve: The tricuspid valve appears structurally normal.
Pulmonic Valve: The pulmonic valve is structurally normal. There is no pulmonic regurgitation present.
Thrombus: None seen.
Mass: None seen.
Aorta: The aortic root size is normal.
Pulmonary Artery: The pulmonary artery is normal.
Pulmonary Veins: All pulmonary veins appear normal.
Conclusion:
Ophthalmology Consult Report
Subjective:
Diagnosis:
Preexisting Conditions:
Current Medications:
Reason for Presentation:
OPHTHALMIC EXAM
RIGHT EYE:
Schirmer Tear Test: mm/min
IOP: mmHg
Fluorescein Stain: Negative corneal stain
Tear Film Break-Up Time: Not examined
Direct Pupillary Light Reflex: Brisk and complete direct PLR
Indirect Pupillary Light Reflex (OD -> OS): Brisk and complete indirect PLR
Dazzle Reflex: +
Hand Menace Response: +
Palpebral Reflex: +
Globe: Normal
Discharge: Normal
Eyelids: Normal
Conjunctiva: Normal
Cornea: Normal
Anterior Chamber: Normal
Iris: Normal
Pupil: Normal
Lens: Normal
Vitreous: Normal
Retina: Normal
Optic Nerve: Normal
Iridocorneal Angle: 1 out of 4 - Wide Open
LEFT EYE:
Schirmer Tear Test: -- mm/min
IOP: -- mmHg
Fluorescein Stain: Negative corneal stain
Tear Film Break-Up Time: Not examined
Direct Pupillary Light Reflex: Brisk and complete direct PLR
Indirect Pupillary Light Reflex (OS -> OD): Brisk and complete indirect PLR
Dazzle Reflex: +
Hand Menace Response: +
Palpebral Reflex: +
Globe: Normal
Discharge: Normal
Eyelids: Normal
Conjunctiva: Normal
Cornea: Normal
Anterior Chamber: Normal
Iris: Normal
Pupil: Normal
Lens: Normal
Vitreous: Normal
Retina: Normal
Optic Nerve: Normal
Iridocorneal Angle: 1 out of 4 - Wide Open
BOTH EYES:
Assessment and Plan:
Recheck:
Medications:
Procedures:
Diagnostic Results:
Additional Comments and Instructions:
Summary:
Client Communication:
Rehabilitation SOAP
SUBJECTIVE
Presenting Complaint:
Medical History:
Current Medications:
Current Supplements:
Previous Surgery:
Other Medical Concerns:
Allergies:
Tick exposure: Yes/No
ACTIVITY LEVEL
Current Activity:
Ability to do stairs:
Ability to jump:
Elimination postures:
DIET
Current Diet:
Amount:
OTHER
Eating:
Drinking:
Vomiting:
Diarrhea:
Coughing:
Sneezing:
Seizures:
ADDITIONAL NOTES
GOALS FOR TREATMENT
OBJECTIVE
GENERAL
- Ophthalmologic Examination: No discharge or hyperemia OU
- Skin: No erythema, lumps, external parasites noted
- Lymph Notes: Normal peripheral LNs
- Abdomen: Soft and non-painful. No palpable masses or organomegaly
- Lungs: Normal lung sounds in all 4 quadrants. No crackles of wheezes ausculted
- Cardiovascular System: Normal rate and rhythm with strong, synchronous pulses. No murmur ausculted
- Urogenital tract: Bladder small, soft and non-painful. External anatomy appear normal
GAIT ANALYSIS
- Lameness score:
- Observation at a stance:
- Stance analysis:
- Transitions:
SKELETAL SYSTEM
- Palpation of Thoracic Limbs:
- Joints:
- Goniometry:
- Long Bones:
- Palpation of Pelvic Limbs:
- Joints:
- Goniometry:
- Long Bones:
MUSCULAR SYSTEM
- Palpation of Thoracic limbs
- Myofascial tension/ trigger points:
- Muscle atrophy/ asymmetry:
- Brachial girth measurements:
- Palpation of Pelvic limbs
- Myofascial tension/ trigger points:
- Muscle atrophy/ asymmetry:
- Thigh girth measurements:
- Palpation of Paraspinals
- Myofascial tension/ trigger points:
- Muscle atrophy/ asymmetry:
NEUROLOGICAL
- Movement Coordination
- Ability to ambulate independently:
- Neurological gait assessment:
- Postural Reflexes
- Knuckling:
- Hopping:
- Spinal Reflexes
- Patellar:
- Withdrawal:
- Crossed Extensor:
- Perineal:
- Cutaneous Trunci:
- Deep Pain:
- Cranial Nerves:
- Other Observations
-Tone of thoracic limbs:
- Tone of pelvic limbs:
- Spinal hyperesthesia:
- Response to tail jack:
ASSESSMENT
Presumptive Diagnosis:
Diagnosis:
PLAN
Diagnostics:
Medications/treatments:
Client discussion:
Follow-up:
Reproduction Puppy/Kitten Litter
SUBJECTIVE
Litter Info
Breed:
Litter Size:
Age: weeks
Mother Present for Exam: Yes/No
History
Feeding: Nursing well / Bottle-fed / Weaning / Other
Growth Concerns: None noted
Any reported illness, weakness, or abnormalities: None noted
Any prior treatments (deworming, vaccinations, etc.): None / Specify
Additional notes:
OBJECTIVE
Puppy/Kitten #1:
Microchip: None / Scanned and verified / Implated today Microchip number (only if present)
Sex: Male/Female
Weight:
Temperature:
Physical Exam: Normal
ASSESSMENT
Healthy litter
PLAN
Vaccinations:
Deworming:
Additional Treatments or Testing:
Client Discussion:
Follow-Up:
Palliative Care/Euthanasia Appointment
HISTORY
Patient presented for humane euthanasia.
Owner reports that:
PHYSICAL EXAM
Upon exam:
Assessment:
EUTHANASIA
Humane euthanasia was elected/ General cremation was elected/ Private cremation was elected/ Home buried was elected/ A clay paw print was elected
(patient's name) was sedated with Butorphanol 10 mg/mL ( mL) IM, Dexmedetomidine 0.5 mg/mL ( mL) IM, Ketamine 100 mg/mL ( mL) IM
A gauge IVC was placed in the Right/Left vein
(patient's name) was administered Propofol 10mg/mL ( mL) IV followed by Euthasol 390mg/mL ( mL) IV
(patient's name) was auscultated and confirmed deceased by Dr.
Chiropractic
Subjective:
Signalment:
Previous Chiropractic Appointment:
History:
Objective:
Posture Notes:
Static Palpation:
Motion Palpation:
C0:
C1:
C2:
C3:
C4:
C5:
C6:
C7:
T1:
T2:
T3:
T4:
T5:
T6:
T7:
T8:
T9:
T10:
T11:
T12:
T13:
L1:
L2:
L3:
L4:
L5:
L6:
L7:
Sternum:
Rib:
Pelvis:
Sacrum:
Forelimbs:
Digit:
MC:
Acc, Carp:
Olec: Right:
Olec: Left:
Hum: Right:
Hum: Left:
Scap: Right:
Hindlimbs:
Digit:
MT:
Calc: Right:
Calc: Left:
Tibia: Right:
Tibia: Left:
Femur: Right:
Femur: Left:
Recommendations:
Signature:
Acupuncture SOAP
HISTORY
Presenting Complaint:
History:
Medication List:
Additional information:
MUSCULOSKELETAL EVALUATION
Gait: No significant findings
Posture: No significant findings
Neck: No significant findings
Back: No significant findings
Forelimbs: No significant findings
Hindlimbs: No significant findings
NEUROLOGIC EVALUATION
Cranial Nerves: Within normal limits
Postural Reactions: Withing normal limits
Cutaneous Trunci: Present
Deep Pain: Present
ACUPUNCTURE POINTS
Bilateral Points:
Left Points:
Right Points:
Midline Points:
ELECTRO-ACUPUNCTURE
Points:
Time:
Setting:
REHABILITATION EXERCISES
SUMMARY
After an acupuncture treatment, your pet may be more quiet and lethargic for about 24 hours. I recommend letting them rest and keeping their activities low key for the first 24 hours after their treatment. Soreness following an adjustment can happen in a small percentage of cases. Please contact Dr. User Name if you have any concerns or questions following your Insert patient's name's treatment.
Treatment Plan:
Additional Recommendations:
RECHECK APPOINTMENT(S)
Based on todays evaluation, we recommend a recheck for [patient] weeks.
Your next appointment is currently scheduled on MM/DD/YYYY
Necropsy Report
Necropsy Report
Date:
Case Number:
Contact(s):
Subject of Exam:
Case Summary:
Specimen(s) Received:
Medical History:
Necropsy:
Gross Findings:
Radiographic Findings:
Interpretations and conclusion:
Vet to Vet Daily Rounds
Write a summary of the case in one or several paragraphs that chronologically reviews a hospitalized case. Include the presenting complaint, number of days in the hospital (day 1, day 2, etc.), current/ active problem list or diagnoses, pertinent diagnostics results or pending results, current treatment plan, and goals of treatment. Then describe how the patient is doing and if there are any recent new concerns.
Output for visit:
Day 1:
Day 2:
Day 3:
Current/Active Problem List or Diagnoses:
Pertinent Diagnostics Results:
Current Treatment Plan:
Goals of Treatment:
Imaging
Radiograph Report (General Practice)
Patient Name:
Species/Breed:
Age / Sex / Weight:
Owner Name:
Date:
Type of Study: Thoracic/Abdominal/Neuro/Extremity Radiographs
If Extremity selected, specify: Hind Limb/ Left Hind Limb/ Right Forelimb/ Left Forelimb
Clinical Concern:
Findings: [Objective imaging findings organized by relevant anatomical structures or systems. Use descriptive language only—no interpretations. Structure as bullet points or paragraphs depending on complexity. To be put in prompt section]
Impressions/Interpretations: [Summarize the radiologist's interpretation and differential diagnoses based on findings. Prioritize most likely diagnoses. State if findings correlate with clinical signs. Note if any findings are urgent or critical. E.g.: “Findings most consistent with left-sided congestive heart failure. Differentials include dilated cardiomyopathy vs chronic mitral valve disease.” To be put in prompt section]
Recommendations:
Radiograph Report (Specialty)
Patient Name:
Species/Breed:
Age / Sex / Weight:
Owner Name:
Date of Study:
Type of Study: Thoracic/Abdominal/Neuro/Extremity Radiographs
If Extremity selected, specify: Hind Limb - Left Hind Limb - Right Forelimb - Left Forelimb
Clinical Concern:
Imaging Overview:
Findings: [Objective imaging findings organized by relevant anatomical structures or systems. Use descriptive language only—no interpretations. Structure as bullet points or paragraphs depending on complexity. To be put in prompt section]
Impressions/Interpretations: [Summarize the radiologist's interpretation and differential diagnoses based on findings. Prioritize most likely diagnoses. State if findings correlate with clinical signs. Note if any findings are urgent or critical. E.g.: “Findings most consistent with left-sided congestive heart failure. Differentials include dilated cardiomyopathy vs chronic mitral valve disease.” To be put in prompt section]
Recommendations:
CT report
Patient Name:
Species/Breed:
Age / Sex / Weight:
Owner Name:
Date of Study:
Anatomical Region of Study:
Clinical Concern:
Imaging Overview:
Findings: [Objective CT findings organized by anatomical structures or systems. Use descriptive language only—no interpretations. Structure as bullet points or paragraphs depending on complexity. To be put in prompt section]
Impressions/Interpretations:[Summarize the radiologist's interpretation and differential diagnoses based on CT findings. Prioritize most likely diagnoses. State if findings correlate with clinical signs. Note if any findings are urgent or critical. E.g.: “Findings most consistent with metastatic pulmonary nodules. Differentials include primary pulmonary neoplasia versus granulomatous disease. To be put in prompt section]
Recommendations:
MRI report
Patient Name:
Species/Breed:
Age / Sex / Weight:
Owner Name:
Date of Study:
Anatomical Region of Study:
Clinical Concern:
Imaging Overview:
Findings: [Objective MRI findings organized by anatomical structures or systems. Use descriptive language only—no interpretations. Structure as bullet points or paragraphs depending on complexity. To put put in prompt section]
Impressions/Interpretations:[Summarize the radiologist's interpretation and differential diagnoses based on MRI findings. Prioritize most likely diagnoses. State if findings correlate with clinical signs. Note if any findings are urgent or critical.E.g.: “Findings most consistent with intervertebral disc extrusion at T13-L1 causing severe spinal cord compression.” To be added in the prompt]
Recommendations:
Ultrasound report
Patient Name:
Species/Breed:
Age / Sex / Weight:
Owner Name:
Referring Veterinarian / Clinic:
Date of Study:
Anatomical Region of Study: Full abdominal ultrasound/ specific organ.
Clinical Concern:
Imaging Overview:
Findings:
Liver:
Gallbladder and Biliary System:
Spleen:
Kidneys:
Urinary Bladder:
Stomach and Small Intestine:
Colon:
Pancreas:
Adrenal Glands:
Lymph Nodes:
Peritoneal Cavity:
Other Structures / Comments:
Impressions/Interpretations:[Summary of most likely diagnoses and correlation with clinical signs. Prioritize major findings.E.g.: “Findings most consistent with bilateral nephropathy. Differentials include chronic interstitial nephritis vs glomerular disease.”]
Recommendations:
AFAST/TFAST Ultrasound Report
Patient Name:
Species/Breed:
Age / Sex / Weight:
Owner Name:
Date of Study:
Type of Study: AFAST/TFAST OR AFAST ONLY OR TFAST ONLY
AFAST
Performed an AFAST ultrasound evaluation assessing the following sites:
Diaphragmatico-Hepatic (DH) View: No free fluid detected. Liver appears normal in echotexture and position.
Spleno-Renal (SR) View: No free fluid detected. Spleen and left kidney appear normal.
Cysto-Colic (CC) View: No free fluid detected. Urinary bladder and colon appear normal.
Hepato-Renal (HR) View: No free fluid detected. Gallbladder and right kidney appear normal.
Intestinal Tract: No evidence of plication, obstruction, or abnormal motility.
Mesentery and Serosal Detail: Serosal detail is crisp. No evidence of effusion or echogenic fat.
Diaphragm: No abnormal motion or appearance noted.
Overall AFAST Assessment: Negative for abdominal free fluid.
TFAST
Performed a TFAST ultrasound evaluation assessing the following sites:
Chest Tube Site (CTS) – Right: No evidence of pleural effusion or lung point. Normal glide sign present.
Chest Tube Site (CTS) – Left: No evidence of pleural effusion or lung point. Normal glide sign present.
Pericardial Site (PCS) – Right: No pericardial effusion detected.
Pericardial Site (PCS) – Left: No pericardial effusion detected.
Diaphragmatico-Hepatic (DH) View: No pleural or peritoneal effusion detected at this site.
Caudal Thoracic (CT) View: No signs of B-lines, consolidation, or pleural effusion.
Overall TFAST Assessment: Negative for pleural or pericardial effusion. Normal lung glide observed bilaterally
Canine Templates
Prescrotal Neuter Surgery Report
The patient was placed in dorsal recumbency and the surgical site was clipped of hair. The prescrotal region was scrubbed with chlorhexidine and alcohol allowing for 5 minutes of contact time. The prescrotal region was draped in a sterile manner. A __ cm skin incision was made with a #__ blade in the prescrotal region. The subcutaneous tissue was sharply incised to the level of the external spermatic fascia. The left testis was exteriorized and the spermatic fascia stripped via manual traction. The spermatic cord and vessels were double ligated with _____ knots. The testicle was sharply excised. Hemostasis was ensured before releasing the transected cord. The right testicle was excised in the same manner. The subcutaneous tissue and skin were closed via routine two-layer closure.
- Subcutaneous closure as follows: _______ (suture pattern)
- Skin closure as follows: _______ (suture pattern)
- Suture material utilized: _______
Equine Templates
Physical Therapy
Subjective:
Signalment:
Previous Physical Therapy Exam:
History:
Objective:
Skin/Incisions:
Heart rate:
Temperature:
Respiratory rate:
Musculoskeletal:
Skin:
Cardiovascular:
Neurological:
POSTURE/GAIT:
General Observation:
Preop/Injury Lameness: Walk: Trot:
Postop/Injury Lameness: Walk: Trot:
Standing Limb Position:
Sitting Limb Position:
RANGE OF MOTION:
Hip: Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
Stifle: Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
Hock: Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
Shoulder: Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
Elbow: Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
Carpus: Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
Other:
PALPATION:
Forelimb:
Hind Limb:
Spine:
Other:
SPECIAL TESTS:
Neurologic:
Orthopedic:
Functional:
Other:
TREATMENT:
Modalities: Interferential Current OR Neuromuscular Electrical Stimulation OR Other Stim OR Ultrasound OR Ice OR Heat OR Other
Manual: Massage OR Joint Mobilization OR Passive Range of Motion OR Other:
TherEx: Gait Training OR Aquatic OR Functional OR Swiss Ball OR Foam Roll OR Owner Education OR Protocol Review OR Other:
ASSESSMENT:
Decrease Pain:
Decrease Edema:
Increase Weight-bearing:
Independent Home Exercise Program:
Return to Previous Function:
Other:
PLAN:
Return Visit:
Call for Follow-up:
Call DVM:
Other:
Signature:
Lameness Exam
Subjective:
Client name:
Date of examination:
Horse name:
Signalment:
Color / identifying markings:
Microchip / tattoo:
Weight:
Use / discipline: (pleasure, hunter, jumper, dressage, racing, etc.)
History:
Primary concern:
Limb(s) affected:
Duration of lameness:
Onset: Acute / Gradual
When lameness occurs: At rest /During work/ After exercise
Severity reported by owner:
Previous injuries:
Previous lameness episodes:
Recent trauma:
Shoeing / trimming schedule:
Last farrier visit:
Recent changes in: workload/ footing/ tack/ rider
Current medications / supplements:
Objective
Vital:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: Pink and moist
Capillary refill time: < 2 sec
Body condition score:
Static Examination
Posture
Weight shifting:
Pointing limb:
Abnormal stance:
Hoof Examination
Right front:
Left front:
Right hind:
Left hind:
Hoof testers response:
Palpation
Left Front Limb
Heat:
Swelling:
Pain on palpation:
Right Front Limb
Heat:
Swelling:
Pain on palpation:
Left Hind Limb
Heat:
Swelling:
Pain on palpation:
Right Hind Limb
Heat:
Swelling:
Pain on palpation:
Neck and Back
Muscle symmetry:
Pain on palpation:
Range of Motion
Left Hind
Leg lift:
Protraction:
Retraction:
Right Hind
Leg lift:
Protraction:
Retraction:
Dynamic Examination
Walk
Straight line:
Left circle:
Right circle:
Head movement:
Hip movement:
Trot
Straight line:
Left circle:
Right circle:
Head bob:
Hip hike / pelvic asymmetry:
Lunging (clockwise / counterclockwise):
AAEP Lameness Score
0 – No lameness
1 – Difficult to observe, inconsistent
2 – Difficult to observe at walk/trot, consistent under certain conditions
3 – Consistent lameness at trot
4 – Obvious lameness with marked head/hip movement
5 – Minimal weight bearing / inability to move
Score: ___ / 5
Limb(s) affected:
Flexion Tests (held ~30 seconds unless otherwise noted)
Left Front
Upper limb:
Carpus:
Lower limb:
Full limb:
Right Front
Upper limb:
Carpus:
Lower limb:
Full limb:
Left Hind
Upper limb:
Lower limb:
Full limb:
Right Hind
Upper limb:
Lower limb:
Full limb:
Flexion response grading:
0 – no response
1 – mild
2 – moderate
3 – marked
Diagnostic Regional Anesthesia (Nerve Blocks)
Block performed:
Sequence of blocks:
• Palmar digital
• Abaxial sesamoid
• Low four-point
• High four-point
• Tibial / peroneal
• Other
Response to block:
• No improvement
• Partial improvement
• Significant improvement
• Lameness resolved
Imaging
Radiographs:
Views taken:
Findings:
Ultrasound:
Structures examined:
Findings:
Additional Imaging:
MRI / CT / Scintigraphy:
Assessment
Primary diagnosis:
Suspected anatomical location:
Differential diagnoses:
Severity of lameness:
Plan
Further diagnostics recommended:
Treatment options discussed:
Medications:
Farrier recommendations:
Exercise restrictions:
Rehabilitation plan:
Recheck timeline:
Acupuncture/Chiropractic Exam
Client Information
Name:
Visit date:
Patient Information
Name:
Breed:
Age / DOB:
Sex:
Color:
Microchip:
Weight:
Subjective:
Presenting Concerns:
Reason for visit:
Medical History:
Previous injuries or conditions:
Performance concerns:
Diet:
Supplements:
Current Medications:
Physical Exam:
Mentation / attitude: BAR (bright, alert, responsive)
General conformation: No abnormal findings
Defecation / urination / drinking / eating:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: Pink and moist
Capillary refill time: < 2 seconds
Hydration status: Normal
Body condition score:
Musculoskeletal Examination
Left Front Limb:
Right Front Limb:
Left Hind Limb:
Right Hind Limb:
Neck & Back:
Hoof Examination
Left front:
Right front:
Left hind:
Right hind:
Posture, Gait, and Flexion Testing
Stance and Posture at Rest:
Gait in Motion: Walk: Trot: Circle / lunge (if performed):
Flexion Testing
Left front full limb:
Right front full limb:
Left hind distal limb:
Left hind upper limb:
Right hind distal limb:
Right hind upper limb:
Diagnostic Regional Analgesia
Regional anesthesia performed:
Block location:
Response to block:
Diagnostic Acupuncture Point Scan
Bilateral Points:
Left-Sided Points:
Right-Sided Points:
Midline Points:
Acupuncture Treatment
Type of Acupuncture: Manual / Dry needle / Aquapuncture / Electro-acupuncture
Points Treated
Bilateral points:
Left points:
Right points:
Midline points:
Electro-Acupuncture
Points used:
Treatment time:
Frequency / setting:
Chiropractic Adjustment
TMJ:
Poll:
Cervical spine (neck):
Thoracic spine:
Lumbar spine:
Pelvis:
Sacrum:
Forelimbs:
Hindlimbs:
Imaging
Radiographs:
Ultrasound:
Assessment
Primary diagnosis / concern:
Areas of restriction or dysfunction:
Traditional Chinese Veterinary Medicine (TCVM) pattern (if used):
Plan
Treatment Recommendations:
Acupuncture frequency:
Chiropractic follow-up:
Exercise / rehabilitation recommendations:
Farrier recommendations:
Client Discussion:
Pre-purchase exam
Vendor’s Name:
Duration vendor has owned:
Veterinarian for party:
Purchaser's Name:
Intended use by purchaser:
Veterinarian for party:
Conflict of interest: None noted
Patient Information:
Name:
Breed:
Age:
Sex:
Color:
Microchip:
Weight:
History:
Stabling and Pasture:
Diet & Supplements:
Vaccination:
Deworming:
Colic or gastrointestinal disease: None
Respiratory disease: None
Ocular disease: None
Lameness: None
Injuries/scarring: None
Back discomfort (including withers and sacroiliac regions): None
Dental:
Allergies: None
Hernia as a foal: None
Farriery:
Previous foaling:
Objectionable vices: None
Current diet:
Current medications/supplements:
Current work level/discipline:
Objective:
Mentation/Attitude: BAR
General Conformation: No abnormal findings
D/U/D/E:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: pink/moist. CRT <2sec.
Hydration Status: Normal
BCS:
Pre and Post Exercise Exam:
Cardiovascular exam
- Pre-exercise: Normal auscultation of heart rate and rhythm, lacking signs of murmur or
arrhythmia. Jugular veins patent. Normal mucus membrane colour and capillary refill time.
- Post-exercise: Normal reduction of heart rate with recovery.
Respiratory exam
- Pre-exercise: No coughing or nasal discharge, normal auscultation of lungs and trachea, no upper respiratory noises.
- Post-exercise: No coughing or abnormal respiratory noise. No evidence of exercise intolerance with satisfactory conditioning.
Physical Exam:
Ophthalmic: Appears visual. Cornea and lens clear. Normal menace response. Eyelids normal.
Ears/Nose/Neck: All within normal limits
Oral/Dental: Nicely aligned dentition with normal wear, no retained caps.
Abdominal: Adequate borborygmi in all 4 quadrants. No scar on midline palpation
Lymph Nodes: Mandibular lymph nodes bilaterally symmetric (1.5 cm), non-painful, moveable.
Integumentary: Clean, shiny haircoat of appropriate length for season.
Neurologic: Appears normal with no ataxia noted. Full neruological exam not performed
Urogenital: External anatomy normal, good perineal conformation.
Rectal: Not performed
Muscoloskeletal
Left Front Leg:
Right Front Leg:
Left Hind Leg:
Right Hind Leg:
Neck & Back:
Hooves
Right Front:
Left Front:
Right Hind:
Left Hind:
Stance, Gait and Flexion Testing
Stance and Posture at Rest: Balanced, neutral posture.
Giant in Motion: The horse longed adequately in both a clock-wise and counter clock-wise direction. No lameness or reluctance to perform was observed during this exercise.
Flexion Testing:
Left Front Full Limb: within normal limits
Right Front Full Limb: within normal limits
Left Hind Distal Limb: within normal limits
Left Hind Upper Limb: within normal limits
Right Hind Distal Limb: within normal limits
Right Hind Upper Limb: within normal limits
Imaging:
Disclaimer: Image interpretation is based solely on the attending general practitioner’s opinion. Referral for opinion by a board certified veterinary radiologist is at the purchaser's discretion.
Radiograph:
- Front feet: Declined
- Carpus: Declined
- Fetlocks: Declined
- Hocks: Declined
- Stifles: Declined
- Cervical: Declined
- Back/Wither: Declined
- Skull: Declined
- Vendor provided radiographs: No
- Radiograph referral to radiology specialist: Declined
Ultrasound:
Foal Exam
Client Information
Name:
Visit date:
Patient Information
Name:
Breed:
Age / DOB:
Sex:
Color:
Microchip:
Weight:
Subjective:
Dam’s number of previous foals:
Dam: any previous foal medical issues? none reported
Gestation length: 340 days
Gestation complications: none reported
Gestation vaccinations of dam: influenza, tetanus; EHV-1,4 at months 5,7,9
Foaling length (hours): <1 hour
Assisted birth? yes/no
Has foal stood? yes/no
Time to first standing (hours): <1 hour
Has foal nursed? yes/no
Time to first nurse (hours): <2 hours
Colostrum given? yes/no
Volume of colostrum given (mL)? -- mL
Passed meconium?: yes/no
Enema given?: yes/no
Urinated?: yes/no
Umbilicus dipped?: yes/no
Presenting complaint:
History:
Treatments administered:
Physical Exam:
Temperature:
Pulse:
Respiratory rate:
Mucous membranes: pale pink, moist, CRT <2 seconds, no petechiae
Hydration status: within normal limits
Demeanour: bright, alert and responsive
Behaviour: follows mare & feeding regularly with good latch and swallowing
Cardiovascular: no murmurs or arrhythmias auscultated
Respiratory: no adventitious lung sounds auscultated bilaterally
Abdominal: adequate borborygmi in all 4 quadrants, meconium passed and no colic signs or straining
Neurologic: mentation appropriate, no ataxia noted at a walk
Joints: no joint swelling, heat of effusion, all 4 limbs
Umbilicus: clean and dry, no outward evidence of infection
Conformation: all 4 limbs straight, no evidence of angular limb deformities or tendon laxity or contraction; forehead not excessively domed.
Integument: clean shiny hair coat, no evidence of dysmaturity
Urogenital: urinating; healthy external anatomy
Ophthalmic: no abnormalities detected
Assessment
Diagnostics:
Medications/Treatments:
Client Discussion:
Dentistry
SUBJECTIVE:
Client Name:
Date of procedure:
Patient Signalment:
Color and/or defining feature:
Microchip:
Weight:
History:
Last Float Date:
OBJECTIVE:
Vitals:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: Pink and moist
Capillary Refill Time: <2 Sec
BCS:
PHYSICAL EXAM
Attitude/Behavior: Within normal limits
Hydration: Euhydrated
Nose/Throat: Within normal limits
Eyes: Within normal limits
Ears: Within Normal Limits
Mouth/Teeth: Within normal limits
Heart/Blood Vessels: Within normal limits.
Lungs/Airways: Within normal limits
Abdomen: Within normal limits.
Gastrointestinal System: Within normal limits. 4 quadrants auscultate normally.
Coat/Skin/Hooves: Within Normal Limits
Lymph Nodes: Within normal limits
Musculoskeletal: Within Normal Limits
Nervous System: Within normal limits
Urinary/Genitals: Within normal limits
Other:
PROCEDURE:
Sedation:
Dental Exam:
ORAL EXAM
Enamel Points:
Buccal/Lingual Lacerations, Calluses or Abrasions:
Tooth Length:
Infundibular Caries:
Diastema/Diastemata:
Periodontal Pockets:
Other Findings:
Float Procedure Note:
Location During Float:
Procedure Notes:
PLAN:
Dental Recommendations
Recommended Procedures:
Follow-up Plan and Future Dental Care:
Dental Exam/ Procedure Report
SUBJECTIVE:
Client Name:
Date of procedure:
Patient Signalment:
Color and/or defining feature:
Microchip:
Weight:
History:
Last Float Date:
OBJECTIVE:
Vitals:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: Pink and moist
Capillary Refill Time: <2 Sec
BCS:
PHYSICAL EXAM
Attitude/Behavior: Within normal limits
Hydration: Euhydrated
Nose/Throat: Within normal limits
Eyes: Within normal limits
Ears: Within Normal Limits
Mouth/Teeth: Within normal limits
Heart/Blood Vessels: Within normal limits.
Lungs/Airways: Within normal limits
Abdomen: Within normal limits.
Gastrointestinal System: Within normal limits. 4 quadrants auscultate normally.
Coat/Skin/Hooves: Within Normal Limits
Lymph Nodes: Within normal limits
Musculoskeletal: Within Normal Limits
Nervous System: Within normal limits
Urinary/Genitals: Within normal limits
Other:
PROCEDURE:
Sedation Used:
- Drug Name 1: Dose in mg (Volume in mL) Route of administration
- Drug Name 2: Dose in mg (Volume in mL) Route of administration
Additional Notes:
Dental Exam
External examination of head and neck: No abnormalities noted
Oral Exam:
Enamel Points:
Buccal/Lingual Lacerations, Calluses or Abrasions:
Tooth Length:
Infundibular Caries:
Diastema/Diastemata:
Periodontal Pockets:
Other Findings:
Float Procedure Note
Location During Float:
Procedure Notes:
Plan:
Dental Recommendations:
Recommended Procedures:
Follow-up Plan and Future Dental Care:
Castration Report
Client Information
Name:
Visit date:
Patient Information
Name:
Breed:
Age / DOB:
Sex:
Color:
Microchip:
Weight:
Pre-Operative Exam:
T: WNL
P: WNL
R: WNL
Cardiopulmonary Auscultation: No abnormalities detected
Palpation of Inguinal Area/Testicles: Two normally descended testicles; or Cryptorchid - specify left, right, or bilateral
History of Previous Illness/Surgery: N/A
Tetanus Vaccination Status: Current/Administered today/Unknown
Premedication and Anesthesia
Premedication: Detomidine (dose), Butorphanol (dose), [Route]
Anesthesia Protocol: Induction with Ketamine/Diazepam; or Induction with , maintained on Triple Drip
Local Anesthesia: Lidocaine,[ Volume, Location of block]
Surgical Report:
A skin incision was made over the left/right testicle. For closed: The spermatic cord and vaginal tunic were isolated and clamped together using a Carmalt forceps.
For open: The vaginal tunic was opened to expose the testicle directly. The testicle and cord structures were exteriorized, and the mesorchium was bluntly dissected.
For modified: The vaginal tunic was partially incised to allow limited visualization of the cord structures without full dissection.
The spermatic cord was ligated/crushed using an emasculator in nut-to-nut orientation for minimum two minutes or as specified. Ligatures were not placed unless otherwise stated. Hemostasis was confirmed prior to cord release.
The procedure was repeated on the contralateral/same side. Both testicles were removed. The incisions were left open to heal by second intention. The surgical site was inspected for bleeding or complications. The patient recovered uneventfully from anesthesia.
No sutures were placed; incisions left open for drainage unless otherwise stated.
Complications: None observed/minor swelling/hemorrhage
Post-Operative Care and Medications
Post-Operative Medications:
- NSAIDs: Phenylbutazone [(dose), Route, Frequency]
- Antibiotics: Penicillin [(dose), Route, Frequency, or N/A]
- Tetanus Vaccine: Administered [IM, L neck, or No]
- Tetanus Antitoxin: Administered [IM, R neck, or No]
Instructions for Owner:
- Monitoring: Monitor for swelling, bleeding, signs of infection. Include any additional concerns mentioned by veterinarian.
- Exercise:
- Follow-up:
Livestock Templates
Farm Animal SOAP
SUBJECTIVE:
Signalment:
History:
OBJECTIVE:
Vitals:
Temperature:
Heart rate:
Respiratory rate:
Mucous membranes: Pink and moist
Capillary Refill Time: <2 Sec
BCS:
PHYSICAL EXAM
Attitude/Behavior: Within normal limits
Hydration: Euhydrated
Nose/Throat: Within normal limits
Eyes: Within normal limits
Ears: Within Normal Limits
Mouth/Teeth: Within normal limits
Heart/Blood Vessels: Within normal limits.
Lungs/Airways: Within normal limits
Abdomen: Within normal limits.
Gastrointestinal System: Within normal limits. 4 quadrants auscultate normally.
Coat/Skin/Hooves: Within Normal Limits
Lymph Nodes: Within normal limits
Musculoskeletal: Within Normal Limits
Nervous System: Within normal limits
Urinary/Genitals: Within normal limits
Other:
ASSESSMENT:
Treatment Plan:
Instructions to Owner:
1- Product:
Amount:
Route:
Frequency:
Duration:
2- Product:
Amount:
Route:
Frequency:
Duration:
Withdrawal Instructions:
Milk withdrawal: Hrs / Days
Meat withdrawal: Hrs / Days
Milk from this animal, taken at the am/pm milking, may go into the tank on .
if administered as prescribed.
Milk from this animal must be subject to inhibitor Testing before the milk may go into tank.
The recommended date for Inhibitor Testing is the am/pm of .
This animal may be shipped for slaughter on .
Ruminant Herd Health
Client and Visit Information
Name:
Visit Date:
Provider:
Herd Health
Reproductive Status:
Other Observations:
Individual Animals:
Reproductive Status:
Other Observations:
Recommendations:
Avian Templates
Exotics Avian SOAP
CLIENT / CASE INFORMATION
Code Status:
Is this a referral?:
Regular DVM / Hospital:
Pet Insurance:
Owner Concerns:
SUBJECTIVE
Presenting complaint:
Duration:
Activity level:
Appetite:
Water intake:
Specific clinical signs (sneezing, vomiting, regurgitation, lethargy, etc.):
Droppings normal?:
Behavior changes?:
Patient Information
Species:
Age:
Gender:
Method used to determine sex:
Reproductive status:
Egg laying history:
Molting:
Flight status (flighted / wing clipped):
Source of animal (breeder, rescue, store, etc.):
Date acquired:
Number of previous owners:
Quarantine period after acquisition:
Contact with other animals:
Other birds in household:
Other pets in household:
Husbandry & Environment
Type of enclosure:
Time spent outside enclosure:
Substrate / cage liner:
Cleaning & disinfection routine:
Bathing routine:
Lighting:
• Type of lighting:
• UVB bulb used?:
• Type/brand:
• Distance from bird:
• Frequency of bulb replacement:
Light/Dark cycle:
Environmental exposures:
• Cleaners/sprays
• Candles
• Teflon/non-stick cookware
• Cooking exposure
Age of home:
Environmental factors (drafts, smoke, etc.):
Social interaction:
Recent husbandry/environment changes:
Outdoor access:
Diet:
Diet items offered:
Diet presentation & feeding frequency:
Diet preferences/selective eating:
Eating normally?:
Supplements:
Brand / type:
Water source & consumption:
Medical History
Previous medical conditions:
Historical health concerns:
Current medications:
Adverse drug reactions:
Last medication doses administered:
Refills needed today?:
Public health concerns:
OBJECTIVE
Emotional Assessment
Exam Type:
Behavior:
Posture:
Mentation:
Perching posture:
Vital Parameters:
Weight:
Previous weight / date:
Body Condition Score (BCS): /5
Muscle Condition Score (MCS): /3
Pain Scale: /4
ASA status:
Heart Rate:
Respiratory Rate:
Flight status:
Wing trim:
Pallor:
Dropping characteristics:
Nurse:
Physical Examination
Eyes: Fundic normal OU, cornea/lens/iris clear
Ears: Clear AU
Nares/Cere: Symmetrical, no discharge
Beak: Normal occlusion, healthy keratin
Oral cavity: No mucosal lesions
Tongue: Normal
Choana: Clear with normal/abnormal papillae
Cardiovascular: Normal rate and rhythm. Ulnar refill normal. No murmurs or arrhythmias.
Respiratory: Normal respiratory rate and effort. Clear lung and air sac sounds. No wheezes, crackles, or rubbing.
Crop: No distension
Coelom / GI: Soft concave coelom. No masses palpable
Vent / Urogenital: Vent clean, normal tone. Mucosa pink and moist. Urates normal
Sex: Male / Female / Unknown
Musculoskeletal: Normal wing snap. Normal range of motion. Strong grip strength. Keel muscle condition normal/abnormal
Integument: Feather quality normal/abnormal. Skin intact. Nails normal
Nervous System: Normal posture and perch stance. No neurological deficits. No weakness in pelvic or thoracic limbs
DIAGNOSTICS
Laboratory testing:
Imaging:
Cytology / microbiology:
Other diagnostics:
ASSESSMENT
Primary Assessment:
Differential Diagnoses:
Chronic Health Concerns:
Prognosis:
Historical Problem List / Previous Visits:
PLAN
Husbandry changes discussed:
Husbandry recommendations today:
Diagnostics:
Recommended tests:
Medications / Treatments:
- Medication name:
Dose:
Route:
Frequency:
Duration:
Preventive Care:
Vaccinations (if applicable):
Client Communication:
Additional discussion / client education:
Follow-Up
Recheck interval:
Exotic/Pocket Pet Templates
Exotics Reptile SOAP
CLIENT / CASE INFORMATION
Code Status:
Is this a referral?:
Regular DVM / Hospital:
Pet Insurance:
Owner concerns:
SUBJECTIVE
Presenting complaint:
Duration:
Activity level:
Appetite:
Water intake:
Specific clinical signs (sneezing, vomiting, regurgitation, lethargy, etc.):
Feces/urates normal?:
Behavior changes:
Patient Information
Species:
Age:
Sex:
Method used to determine sex:
Reproductive status:
Egg laying / live birth history:
Source of animal (breeder, store, rescue):
Date acquired:
Number of previous owners:
Quarantine after acquisition:
Contact with other reptiles:
Other reptiles in household:
Other pets in household:
Husbandry / Environment
Type of enclosure:
Time spent outside enclosure:
Substrate:
Cleaning & disinfection routine:
Handling frequency:
Enrichment provided:
Temperature
Basking temperature:
Ambient/high temperature:
Low temperature:
Night temperature:
Temperature monitoring method:
Heat source (lamp, ceramic emitter, heat mat, etc.):
Lighting
UVB lighting used?:
Type/brand:
Distance from animal:
Bulb replacement frequency:
Photoperiod (light/dark cycle):
Humidity
Humidity level:
How humidity is monitored:
Humidity control methods:
Environmental Exposure
Age of home:
Cleaners / sprays / chemicals used near enclosure:
Outdoor exposure:
Recent husbandry changes:
Diet
Diet items offered:
Feeding frequency and presentation:
Diet preferences/selective eating:
Eating normally?:
Gut loading (if feeding insects):
Source of feeder insects:
Supplements (calcium/vitamins):
Brand / type / frequency:
Water source:
Soaking/bathing routine:
Medical History
Previous health issues:
Historical conditions:
Brumation history:
Last shed date:
Was shedding normal?:
Current medications:
Adverse drug reactions:
Last medication dose given:
Refills needed today?:
Public health concerns:
OBJECTIVE
Emotional Assessment
Exam Type:
Behavior:
Mentation:
Body posture / strength:
Vital Parameters
Weight:
Previous weight / date:
Heart Rate (Doppler):
Respiratory Rate:
Body Condition Score (BCS): /5
Muscle Condition Score (MCS): /3
Pain Scale: /4
ASA Status:
Hydration status:
Fecal description:
Nurse:
Physical Examination
Eyes: Corneas clear OU, no discharge or swelling
Ears / tympanum: Intact, no discharge or swelling
Nares: No discharge or discoloration
Head/neck: No swelling or masses
Oropharyngeal: Mucous membranes pink/pigmented and moist. Saliva curtain normal/thick/absent. No hypersalivation. No plaques, masses, or lesions. Beak/jaw structure normal/abnormal
Cardiovascular: Doppler auscultation normal. No murmurs or arrhythmias detected
Respiratory: Normal respiratory rate and effort. No open-mouth breathing. No nasal discharge. No wheezes or crackles. Patient recovered quickly after handling.
Coelomic Cavity / GI: Coelomic palpation normal/abnormal. No masses palpable. Defecation normal/abnormal. Vent pink/pigmented and moist
Vent / Urogenital: Vent mucosa normal on eversion. No masses or lesions. Hemipenal plugs present/absent. No substrate present in vent. Urates/urine normal/abnormal/not observed
Sex: Male / Female / Unknown
Musculoskeletal: Normal strength. Ambulates normally/abnormally. Normal elevation of body from surfaces. Normal grip strength.
Integument: Scales normal/abnormal. Skin intact. No retained shed. No burns, bite wounds, or lesions.
For chelonians: Carapace/plastron normal/abnormal. No pitting, ulceration, or shell deformity
Nervous System: Mentally appropriate. Normal pain perception. Normal ambulation. No neurologic deficits observed.
DIAGNOSTICS
Laboratory testing:
Imaging (radiographs, ultrasound):
Fecal testing:
Cytology / microbiology:
Other diagnostics:
ASSESSMENT:
Primary diagnosis/assessment:
Differential diagnoses:
Chronic health concerns:
Prognosis:
Historical problem list / previous visits:
PLAN
Husbandry changes discussed:
Husbandry recommendations today:
Diagnostics
Recommended diagnostics:
Treatments
Therapeutic plan:
- Medications
Name:
Dose:
Route:
Frequency:
Duration:
Medications dispensed:
Nurse:
Client Communication
Additional discussion / client education:
Follow-Up
Recheck interval:
Monitoring instructions:
Exotics Rabbit and Rodents SOAP
CLIENT / CASE INFORMATION
Code Status:
Is this a referral?:
Regular DVM / Hospital:
Pet Insurance:
Owner concerns:
SUBJECTIVE
Presenting complaint:
Duration:
Activity level:
Appetite:
Water intake:
Specific clinical signs:
• Sneezing / nasal discharge
• Reduced fecal production
• Diarrhea
• Weight loss
• Lethargy
• Dental issues
• Other:
Fecal output normal?:
Urination normal?:
Behavior changes:
Patient Information
Species:
Breed (if applicable):
Age:
Sex:
Method used to determine sex:
Reproductive status (intact/spayed/neutered):
Source of animal (breeder, rescue, store):
Date acquired:
Number of previous owners:
Quarantine after acquisition:
Contact with other animals:
Other small mammals in household:
Bonded companion present? (rabbits/guinea pigs):
Husbandry / Environment
Housing
Description of enclosure:
Time spent outside enclosure:
Bedding/substrate:
Cleaning and disinfection routine:
Temperature of environment (if monitored):
Humidity (if applicable):
Lighting:
Light/Dark cycle:
Environmental factors:
• Drafts
• Smoke exposure
• Cleaners / chemicals
• Other exposures
Social interaction:
Recent environmental changes:
Chew enrichment available? (important for rodents):
Diet:
Diet Composition
Diet items offered:
Feeding frequency and presentation:
Diet preferences / selective eating:
Hay availability:
Hay type:
Pellets:
Brand / amount fed:
Fresh vegetables offered:
Treats:
Species-Specific Diet Questions
Rabbits
- Cecotrope consumption normal?:
- History of GI stasis?:
- Litter habits:
Guinea Pigs
- Vitamin C supplementation?:
- Source of Vitamin C (pellet vs supplement):
Rodents
- Chew toys available?:
- History of incisor overgrowth?:
Supplements
Calcium / vitamin supplements:
Brand / type / frequency:
Water source (bottle/bowl):
Water consumption normal?:
Medical History
Previous medical issues:
Historical conditions:
Dental disease history:
GI stasis history (rabbits/guinea pigs):
Current medications:
Adverse drug reactions:
Last medication dose given:
Public health concerns (zoonotic risk if applicable):
Additional information:
OBJECTIVE
Exam Type:
Behavior:
Mentation:
Handling tolerance:
Vital Parameters:
Weight:
Previous weight / date:
Body Condition Score (BCS): /5
Muscle Condition Score (MCS): /3
Hydration status:
Mucous membranes:
CRT:
Heart rate:
Respiratory rate / effort:
Nurse:
Physical Examination
Eyes: Clear corneas OU, no discharge
Ears: No erythema or discharge AU
Nares: Symmetrical, no discharge
Oral Cavity / Dentition: Incisors normal length and alignment. Molars palpably normal / spurs suspected. Oral mucosa pink and moist. No ulcers or lesions. Hypersalivation present / absent
Cardiovascular: Heart rate and rhythm normal. No murmurs or arrhythmias detected
Respiratory: Normal respiratory rate and effort. No wheezes or crackles. No nasal discharge
Abdomen / Gastrointestinal: Abdomen soft. No distension or palpable masses. GI sounds present / reduced / absent. Feces normal in appearance
Urogenital / Perineal: Perineum clean. No urine scalding. No fecal soiling. Urine appearance normal
Integument: Haircoat clean and normal. Skin intact. No ectoparasites observed. No alopecia or lesions
Musculoskeletal: Normal range of motion. Ambulates normally. Muscle mass appropriate. Feet normal. Nails normal length
Nervous System: Normal mentation. Normal gait. No neurologic deficits observed
DIAGNOSTICS
Fecal testing:
Bloodwork:
Radiographs:
Ultrasound:
Cytology / microbiology:
Other diagnostics:
ASSESSMENT
Primary diagnosis / assessment:
Differential diagnoses:
Chronic health concerns:
Prognosis:
Historical problem list / previous visits:
PLAN
Preventive Care
Vaccinations (if applicable):
Diagnostics
Recommended diagnostics:
Treatments
Therapeutic plan:
- Medication
Name:
Dose:
Route:
Frequency:
Duration:
Husbandry Recommendations
Diet recommendations:
Environmental recommendations:
Dental care recommendations:
Client Communication
Additional discussion / client education:
Follow-Up
Recheck interval:
Monitoring instructions: