A collection of templates you can use and modify.
Glossary
General Workup
Procedure
Detailed Discharge
Humane Euthanasia
Spay Surgery
Controlled Substances
Chiropractic
Rehab Exam Discharge Instructions
Physical Therapy
Integrative Medicine
Adult Canine Wellness
Dog Spay Surgery
Canine Dental Numbered Chart
Dog Neuter Surgery Report
Dog Neuter Surgery
Puppy 8 weeks History Appointment
Canine Vaccine Plan
Cat Report
Adult Feline Wellness
Avian Exotic Template I
Avian Exotic Template II
Farm Animal SOAP
Reptile SOAP
Small Mammal 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-notes
- Click + Create a Custom Note
- Enter a title.
- Copy the given text, then paste it into the main box labeled 1. Initial Command
- {Optional} Add any formatting options in the final box labeled 2. Add optional content formatting instructions
- 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.
And 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
General Workup
Initial Command
Patient Name:
Veterinarian:
Technician:
**HISTORY**
What problem(s) is your pet experiencing:
When did the problem start:
Is the problem the same, better, or worse:
Has a similar problem happened in the past:
Are any medications being administered:
What is the pet's current diet and feeding schedule:
Eating Changes:
Has your pet been vaccinated recently:
Any weight loss:
Any increase or decrease in water consumption:
Any change in bowel movements:
Any exposure to toxins:
Any other medical history:
Additional Notes:
**EXAM**
Nose and Throat: Normal / Abnormal (Remarks)
Mouth/Teeth/Gum: Normal / Abnormal (Remarks)
Eyes and Ears: Normal / Abnormal (Remarks)
Coat and Skin: Normal / Abnormal (Remarks)
Lymph Nodes: Normal / Abnormal (Remarks)
Legs/Paws/Back: Normal / Abnormal (Remarks)
Nervous System: Normal / Abnormal (Remarks)
Heart and Lungs: Normal / Abnormal (Remarks)
GI Tract/Abdomen: Normal / Abnormal (Remarks)
Urinary and Genitals: Normal / Abnormal (Remarks)
**LABRATORY FINDINGS**
Radiograph: Thorax / Skull / Abdomen / Other view (Remarks)
Bloodwork: (Results)
Urinalysis: (Results)
Fecal: (Results)
Heartworm Test/Triple Snap Test: (Results)
No diagnostics performed
**ASSESSMENT & PLAN**
Assessment & Diagnosis: (To be filled in)
Additional Notes:
Treatment:
Prescriptions:
Plan:
**RECHECK**:
Procedure
Patient Name:
Owner Name:
Species:
Breed:
Age:
Sex:
Weight:
Date of Surgery:
Surgeon:
Assistant:
Anesthetist:
Surgery Start Time:
Surgery End Time:
Pre-Surgical Diagnosis:
Surgical Procedure Performed:
Anesthetic Protocol:
Induction Agent and Dose:
Maintenance Agent and Dose:
Analgesia and Dose:
Surgical Findings:
Surgical Procedure Description (Step-by-Step):
Complications:
Estimated Blood Loss:
Samples Taken (If Any):
Post-Operative Instructions:
Medications Prescribed:
Special Instructions for Owner:
Follow-Up Appointment:
Notes:
Surgeon's Signature:
Date:
Detailed Discharge
**Reason for the Visit:**
**Objective Findings**:
**Treatment Plan**:
**Discharge Summary**:
General Comment on the Visit:
Preventative Care:
Upcoming Appointments:
Diagnosis and Treatment:
Monitoring and Follow-up Instructions:
Closing Remark:
Humane 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.
Spay Surgery
Patient presented for . Owner has no questions or concerns at this time.
Scanned patient for a microchip. #
Tech:
BAR. **Temp:**. **Pulse:** **Resp:** WNL. **Gums:** pink/moist. **CRT:** <2.
Placed a. IV catheter in left front leg.
Administered mL Cefazolin mg/mL via sub q injection.
Administered mL Rimadyl mg/mL via sub q injection.
Administered mL of Norm R IV fluids via IV catheter injection.
Collected blood for in-house CBC, Chem 17 and Lytes…see lab for further details…all WNL excepting .
Sedation:
Drugs used for intubation and surgical prep: mL Xylazine mg/mL, mL Atropine mg/mL,
mL Torb mg/mL, mL Ketamine mg/mL and mL Valium mg/mL (only gave mL of Ket/Val combo) via IV catheter injection. Intubated patient with a size. tube and placed patient on ISO/O2 for duration of procedure. Patient received mL of Norm R IV fluids.
Performed routine spay, no complications.
Administered mL of the Ket/Val combo that was previously drawn up Post Op.
Dispensed Cephalexin mg capsules, give capsule orally every 12 hours for 7 days or longer pending patient’s response.
Dispensed Carprofen mg tablets, give tablet orally every 12 hours for 2-4 days STARTING tomorrow morning, if patient is doing well reduce to 1/2 tablet orally every 24 hours for 3-4 more days.
See discharge instructions attached to record for further details.
Controlled Substances
Date:
Client Name:
ID#:
Pet Name:
Species:
Ordered by:
Dispensed/Administered by:
Amount Dispensed or Administered:
Chiropractic
**Prior Manipulation?:**
**History:**
**Posture/Ambling 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:**
Rehab Exam Discharge Instructions
**Presenting Complaint:**
**Physical and Diagnostic Examination:**
**GaitRite Objective Gait Analysis:**
**Diagnostic MSK Ultrasound: Final report pending
Medications:**
Please continue all medications and supplements as previously directed.
**Glucosamine and Chondroitin Sulfate: Dasuquin Advanced (Nutramax Labs) is recommended.
Joint health is an important aspect of your pet's recovery as well as long-term function.
Dasuquin Advanced is a joint health supplement that works by supporting cartilage production and blocking enzymes that break down cartilage within the joint. We specifically recommend this product as it is the only veterinary joint supplement with clinical studies to support its
eficacy. In addition to glucosamine and chondroitin sulfate, Dasuquin Advanced also contains avocado and soy as well as antioxidants which would benefit overall health.
Omega-3 fatty acid supplements (EPA and DHA) in liquid form, from marine sources are recommended. Welactin (from Nutramax Labs) is recommended. While using this supplement it is important to monitor for weight gain or digestive upset. If these concerns arise, diet planning
or dose reduction may be needed.
*If purchasing Welactin, the liquid formulation of Welactin is preferred. Please double the listed body weight dose given on the label (a slow gradual progression to this amount is recommended over 2 weeks while monitoring for gastric upset).
Myos Canine Muscle Formula: Research has shown that better muscle heath leads to better mobility, vitality and quality of life. Myos Canine Muscle Formula is made from an all-natural ingredient Fortetropin (fertilized hen egg yolks). It is considered a natural myostatin-reducing agent and has been clinically proven to increase muscle mass and size. Additionally, itIs been shown to inhibit disuse muscle atrophy in dogs after surgery.
Adequan (polysulfated glycosaminoglycan) is an FDA-approved disease-modifying osteoarthritis drug. It is administered via subcutaneous (under the skin) or intramuscular injections to control signs associated with joint arthritis. Please speak with your primary veterinarian regarding this medication. We recommend dosing at 2 mg/lb, starting with twice
weekly injections for 4 weeks. Following that, you may continue once monthly injections as long as the medication appears to be helping, or you can repeat this series during times of increased discomfort. These continued injections can be performed by your primary veterinarian, or you
can administer the injection at home following instruction by your veterinarian if you are comfortable.
Comments:
Physical Therapy
Fill out this blank medical record based on the transcript below:
**Patient's Name:**
**Date:**
**PHYSICAL EXAMINATION:**
**Skin/Incisions:**
**Heart rate:**
**Color/temp:**
**Respirations:**
**Musculoskeletal:**
**Skin:**
**Cardiovascular:**
**Neurological:**
**POSTURE/GAIT:**
**General Observation:**
**Preop/Injury Lameness:** Walk: Trot:
**Postop/Injury Lameness:** Walk: Trot:
**Standing Limb Position:**
**Sitting Limb Position:**
**Circumference(cm):**
- 70% Femur: Affected/Unaffected Other:
- 80% Humerus: Affected/Unaffected Other:
- Joint Line: Affected/Unaffected Other:
- Other:
**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/GOALS:**
**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:**
DVM Signature:
Integrative Medicine
**SUBJECTIVE:**
**History**:
**Chief Complaint**:
**Clinical Findings:**
**Previous history:**
**Current Medications:**
Acupuncture visit # :
Patient Physical Examination :
Temperature:
Weight:
Pulse:
RR:
MM:
CRT:
Tongue:
Constitution:
Diet:
Body Score:
Shen:
Voice:
Activity Level:
Sleep:
Temp Pref:
Appetite:
Thirst:
Urination:
Coughing:
Sneezing:
Panting:
Vomiting:
Stool:
Stiffness:
Weakness:
Hearing Loss:
Likes Massage:
Paw pads:
Pain:
**OBJECTIVE:**
Body Condition: Your pet's body condition and weight are normal. There is a slightly tucked-in waist and the ribs and spine are palpable.
Ears: Both the ear canal and pinna are normal. Your pet's tympanic membrane (ear drum) is normal and your pet seems to hear fine.
Eyes: Your pet's eye(s) are normal. The eyeball, eyelids and associated structures appear normal. Your pet appears to have normal vision.
GI/Abdominal Palpation: Your pet's abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).
Heart/Cardiovascular: Your pet's heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.
Lungs/Trachea: Your pet's lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.
Lymph nodes/Thyroid gland: Your pet's external lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland.
Mouth/Teeth/Gums: Your pet's oral examination is normal. There is no evidence of tartar on the teeth or gum disease.
Musculoskeletal: Your pet's muscles are in good condition. The skeleton is observed to be normal with no lameness noted.
Nervous System: Your pet's nervous system is normal. There are no observable defects in the nerves, spine cord or brain function.
Nose/Throat: Your pet's nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.
Skin/Haircoat: Your pet's haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.
Urinary/Reproductive: Your pet's urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.
**ASSESSMENT:**
**Differential Diagnosis**:
**Pattern Diagnosis:**
**PLAN :**
**Acupuncture:**
**Local Point:**
**Topographic:**
**Electro-accupuncture:**
**Moxabustion:**
**Acupuncture Points Used:**
**Laser:**
**Chiropractic Listings:**
Takehome Instructions:
Discussed with owner: Alternative/Complimentary/Integrative Veterinary care is not intended to replace the services of conventional medicine. We offer information along with our suggested treatment plans, It should not be misconstrued to mean, imply, or indicate that the products or treatment plans described cure anything, as no such claims are made. ONLY THE BODY CAN HEAL ITSELF, so the nutritional and herbal supplements are not offered as a cure, but rather as aids to the body in re-establishing normal functions.
If clinical signs persist in spite of treatment further diagnostics/treatments may be warranted.
Canine Templates
Adult Canine Wellness
**Consultation history:**
Date:
**POST APPOINTMENT INSTRUCTIONS:**
**Meds:**
**Recheck:**
**Other notes (dc notes, bill, food, etc):**
**RTG?:**
**History:** Routine examination for vaccinations. Doing well at home. Eating and drinking normally. No owner or patient concerns. Good E level/appetite. No v/d/c/s. Normal urine/thirst/feces. **Staff initials:**
**Anal gland expression?**
**Nail trim?**
**Current meds/deworming:**
**Current diet (grain-inclusive? legume-free?):**
**Temperature:** C (aural)
**Pulse:** bpm
**Respiration:** brpm
**Body Condition Score:** BCS 5/9
**Attitude:** BAR, friendly
**Oral cavity/MMs:** MMs pink, moist, CRT<2 sec
**Cardiovascular:** No murmur or arrhythmia auscultated
**Teeth:** NSF
**Respiration:** Clear in all fields, no crackles or wheezes
**Lymph nodes:** Peripheral lymph nodes normal size and symmetrical
**Eyes:** Clear
**Ears:** Clean
**Nasal:** NSF
**Abdominal Palpation:** Soft and comfortable throughout
**Musculoskeletal:** NSF
**Genitourinary:** NSF
**Integumentary:** NSF
**Rectal:** Not examined today
**Nervous:** NSF
**Diagnostics:**
**SNAP4dx -**
**CBC:** n/a
**CHEM/LYTES:** n/a
**Radiographs:** n/a
**Cytology:** n/a
**Vaccinations:**
DH2PP L scap SQ (Vanguard5serial #, expiration:) - **repeat in 1 year/3 years**
Rabies R scap SQ (Defensor3 serial #, expiration:) - **repeat in 1 year/ 3 years**
Bord oral (Nobivac serial #, expiration:) - **repeat in 1 year**
Bord injectable (Vanguard serial #, expiration:) - **repeat in 1 month/year**
Lyme LH SQ (Vanguard, serial #, expiration:) - **repeat in 1 month/1 year**
**Treatment Plan/ Recommendations/ Medications to go home:**
Discussed PE findings and potential vx reactions; no vx 100% protective
Recommend deworming
Recommend flea/tick prevention, Recommend heartworm prevention
Recommend grain inclusive, low legume based diet
Dog Spay Surgery
Pre-Surgical Exam
Pre-Surgical blood work = [add abnormal], otherwise, WNL
**Premeds:**
-Butorphanol 10 mg/mL ( mL) IV
-Buprenorphine 0.5 mg/mL ( mL) IV
-Buprenorphine 0.3 mg/mL ( mL) IV
-Hydromorphone 2 mg/mL ( mL) IV
-Midazolam 5mg/mL ( mL) IV
-Acepromazine 10 mg/mL ( mL) IV
-Acepromazine 1 mg/mL ( mL) IV
-Dexmedetomidine 0.5 mg/mL ( mL) IV
-Ketamine 100mg/mL ( mL) IV
-Alfaxalone 10mg ( mL) IV
**Antiemetics:**
-Cerenia 10 mg/mL ( mL) IV
-Ondansetron 2mg/mL ( mL IV
-Vitamin B12 ( mL) SQ
Placed IVC = gauge R / L cephalic vein
**Routine induction:**
-Propofol 10mg/mL ( mL) IV to effect
-Alfaxalone 10mg/mL ( mL) IV to effect
**Intra-op meds:**
-Lidocaine 20 mg/mL ( mL) local line block
-Bupivacaine 5 mg/mL ( mL) local line block
**Post-op meds:**
-Carprofen 50 mg/mL ( mL) SQ,
-Meloxicam 5mg/mL ( mL) SQ
-Buprenorphine 0.5 mg/mL ( mL) IV
-Buprenorphine 0.3 mg/mL ( mL) IV
-Antisedan 5mg/mL ( mL) IM
-Vitamin B12 ( mL) SQ
Total LRS IVF volume mL
Routine Spay/OVH
-See attachment for anesthesia monitoring
-Notes: uneventful anesthesia
Uneventful recovery
Pulled IVC prior to discharge
E-collar = cm
Microchip
RX:
-Carprofen mg tablets: tab PO q12h x 5d qty: / refills 0
-Gabapentin mg capsules/tablets: tab/cap PO q8-12h x 5 qty: / refills: 1
-Trazodone mg tablets: tab PO q8-12h x 7d qty: . refills 1
-Gabapentin mg/mL suspension: mL PO q8-12h x 5 qty: / refills 1
-Meloxicam mg/m suspensionL: mL PO q12h x 5d qty: / refills:0
Written RX:
-Trazodone mg/mL suspension: mL PO q8-12h x 7d qty: . refills
Prognosis: Good
Follow-up: 1 year for an annual exam or sooner if surgical concerns/complications
Client Education: Advised Owner to feed 1/2 has much food tonight & resume normal feeding tomorrow. Monitor for signs of GI upset, such as vomiting and diarrhea. Advised owner to keep patient relaxed for the rest of the day to sleep off effects of the anesthesia. Advised removal of bandage in place secondary to IV catheter removal when arriving home. Standard Hippo Spay discharge instructions handout given.
Canine Dental Numbered Chart
**Right Upper Quadrant**
101:
102:
103:
104:
105:
106:
107:
108:
109:
110:
**Left Upper Quadrant**
201:
202:
203:
204:
205:
206:
207:
208:
209:
210:
**Left Lower Quadrant**
301:
302:
303:
304:
305:
306:
307:
308:
309:
310:
311:
**Right Lower Quadrant**
401:
402:
403:
404:
405:
406:
407:
408:
409:
410:
411:
Dog 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 #10 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 2 modified Miller's knots. The testicle was sharply exercised. 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: Simple continuous
Skin closure as follows: Buried continuous intradermal with skin glue as needed
Suture material utilized: PDS
Dog Neuter Surgery
Pre-Surgical Exam
Pre-Surgical blood work = (add abnormal), otherwise, WNL
**Premeds:**
-Butorphanol 10 mg/mL ( mL) IV
-Buprenorphine 0.5 mg/mL ( mL) IV
-Buprenorphine 0.3 mg/mL ( mL) IV
-Hydromorphone 2 mg/mL ( mL) IV
-Midazolam 5mg/mL ( mL) IV
-Acepromazine 10 mg/mL ( mL) IV
-Acepromazine 1 mg/mL ( mL) IV
-Dexmedetomidine 0.5 mg/mL ( mL) IV
-Ketamine 100mg/mL ( mL) IV
-Alfaxalone 10mg ( mL) IV
**Antiemetics:**
-Cerenia 10 mg/mL ( mL) IV
-Ondansetron 2mg/mL ( mL IV
Placed IVC = gauge R / L cephalic vein
**Routine induction:**
-Propofol 10mg/mL ( mL) IV to effect
-Alfaxalone 10mg/mL ( mL) IV to effect
**Intra-op meds:**
-Lidocaine 20 mg/mL ( mL) local spermatic cord block
-Bupivacaine 5 mg/mL ( mL) local spermatic cord block
**Post-op meds:**
-Carprofen 50 mg/mL ( mL) SQ,
-Meloxicam 5mg/mL ( mL) SQ
-Buprenorphine 0.5 mg/mL ( mL) IV
-Buprenorphine 0.3 mg/mL ( mL) IV
-Antisedan 5mg/mL ( mL) IM
-Vitamin B12 ( mL) SQ
Total LRS IVF volume mL
Routine Neuter/Castration
-See attachment for anesthesia monitoring
-Notes: uneventful anesthesia
Uneventful recovery
Pulled IVC prior to discharge
E-collar = cm
Microchip:
RX:
-Carprofen mg tablets: tab PO q12h x 5d qty: / refills 0
-Gabapentin mg capsules/tablets: tab/cap PO q8-12h x 5 qty: / refills: 1
-Trazodone mg tablets: tab PO q8-12h x 7d qty: . refills 1
-Gabapentin mg/mL suspension: mL PO q8-12h x 5 qty: / refills 1
-Meloxicam mg/m suspensionL: mL PO q12h x 5d qty: / refills:0
Written RX:
-Trazodone mg/mL suspension: mL PO q8-12h x 7d qty: . refills 1
Prognosis: Good
Follow-up: 1 year for an annual exam or sooner if surgical concerns/complications
Client Education: Advised Owner to feed 1/2 has much food tonight & resume normal feeding tomorrow. Monitor for signs of GI upset, such as vomiting and diarrhea. Advised owner to keep patient relaxed for the rest of the day to sleep off effects of the anesthesia. Advised removal of bandage in place secondary to IV catheter removal when arriving home. Standard Hippo Neuter discharge instructions handout given.
Puppy 8 weeks History Appointment
Date:
Initials:
DVM:
Tech:
Confirmed contact information with owner?
Anyone else need to be added to the file?
Acquired: from a breeder/ from a shelter./from a private party./as a stray.
When?
Health Concerns with {AnimalName}?
Eating habits and diet fed:
Dietary recommendation:
Drinking?
Vomiting?
Diarrhea?
Urination:
Energy level:
Medications (name, doses):
Previous vaccines?
Vaccine reactions?
Discuss vaccination series (Lepto & Lyme):
Review vaccine schedule & importance of yearly health exam:
Vaccine receiving today:
Discuss intestinal parasites & deworming:
Discuss fleas (if applicable):
Discuss HW disease and testing:
Stool sample today and yearly recommended:
Pet insurance trial discussed: Yes/No/Declined/Accepted
Courtesy nail trim? Yes/No
Prebook next visit (book 1 month booster during tech exam)
Issues to address:
**Temperament:**Friendly/Shy/Caution
**Mentation**:BAR/QAR/Dull and Depressed
**mmb colour**:pink/pale pink/pale/purple/blue
**CRT**: <1sec/<2sec/>2sec
**BCS**:
**SARCOPENIA**: NONE-well muscled/mild muscle wasting/moderate muscle wasting/severe muscle wasting
**Hydration Status**: Normal/4-6% hydration/6-8% dehydration/8-10% dehydration
**Integument:**Normal/Abnormal
Eyes:
Ears:
Nose:
Throat:
**Oral Cavity:** Teeth are free from excessive tartar, no gingivitis present/grade 1 periodontal disease/grade 2 periodontal disease/grade 3 periodontal disease/severe periodontal disease occlusion-/normal bite/overbite (type 2 malocclusion) /underbite (type 3 malocclusion)
**Cardiovascular:**Regular rhythm; no murmur detected/heart murmur present
**Respiratory:**Lungs auscultate clear; trachea clear/Abnormal
ABDOMEN/soft non-painful with no palpable masses/tense on palpation/too large for accurate palpation
Genitourinary: {AnimalSexFull}:
Musculoskeletal:
**Neurologic:**No apparent abnormalities/Ambulatory x 4 with no apparent lameness/Abnormal
Lymph Nodes:
**Assessment:**
**Plan:**
Rx: Vaccines (location given):
Medications to go home (dosing calculations with final dosing to go home, duration):
Next steps for the pet:
Next visit:
Any outstanding items needing to be addressed:
Canine Vaccine Plan
**Subjective:**
Presenting for/ DA2PPV/ DA2PPV and Rabies/ DA2PPV and Bordetella inj/ DA2PPV, Bordetella inj and Rabies/ Bordetella/ Bordetella inj and Rabies/ Rabies/ Bordetella oral/ DA2PPV and Bordetella oral/ DA2PPV, Bordetella oral and Rabies]
Eating and drinking: normal
Energy levels: normal
Urinating and defecating: normal
Feces consistency: normal
Food:
Owner concerns:
**Objective:**
Demeanor:
Mentiation: BAR
MM: pink, CRT<2s
Heart: Normal heart and lung sounds, strong synchronous pulses, normal Broncho vesicular sounds
Eyes: appear normal
Ears: appear healthy
Integument: normal
Lymph nodes: palpate normal
Abdomen: palpates normal, no organomegaly appreciated
Mentation: normal
Rectum: appears normal
Dentition: normal
Stifles: normal
Mammary chain: normal
Genital: Both testis descended/ unilateral crypt rt side/ unilateral crypt left side
BCS: /5
**Plan:**
{name} [Vaccinated for/ DA2PPV/ DA2PPV and Rabies/ DA2PPV and Bordetella inj/ DA2PPV, Bordetella inj and Rabies/ Bordetella/ Bordetella inj and Rabies/ Rabies/ Bordetella oral/ DA2PPV and Bordetella oral/ DA2PPV, Bordetella oral and Rabies]
Discussed with owner Echinococcus multilocularis:/ Yes/ No]
Dispensed 1 dose Dolpac/ Dispensed 6 months Dolpac/ Dispensed 12 months Dolpac/ Owner declined deworming/ Dispensed 12 doses Biltricide]
Dispensed Bravecto/ Yellow/ Orange/ Green/ Blue/ Pink]
Discussed with owner omega III supplementation:/ Yes/ No]
Feline Templates
Cat Report
**NAME:**
**PATIENTID**:
**FULLNAME:**
**ID:**
PHONENUMBER:
SPECIES:
BREED:
AGE:
SEX:
ALLERGIES:
**MEDICALALERT:**
**Physical Exam Feline- Exam Date:**
**Chief Complaint today:**
Technician history:
DVM notes:
Behavioral concerns (including changes since last visit): None
**VITAL SIGNS:**
Temperature (F):
Pulse rate (beats/min):
Respiratory rate breaths/min):
Capillary refill time (s):
Weight (lbs):
Pain score: /4
Source of pain:
Were signs of fear, anxiety and/or stress present during examination and if so, what was helpful in reducing the signs?
Body condition score (1-9):
Muscle Condition Score: Normal muscle mass/Mild muscle loss/Moderate muscle loss/Severe muscle loss
Ideal weight (if current weight is not ideal): (lbs) recommended daily calorie intake
Continue feeding to maintain current body condition
Current diet (include treats and food intended for human consumption) and frequency of feeding:
Current medications (include parasite prevention, supplement(s), non prescription and prescription
medications:
Microchip: Yes/No/Declined (1 in 3 pets goes missing during its lifetime)
**Environment:**
Family not present at time of examination, so complete environmental history not able to be discussed: YES/NO
Indoor only: Yes/NO
Indoor mostly with access to a screened porch or fenced yard? No/Yes
Indoor/outdoor: YES/NO
Does pet roam outdoors with exposure to other/unknown cats? No/Yes
Which flea, tick and heartworm prevention is being used?
Last date administered:
Which wildlife is pet exposed to?
When was pet last tested for FeLV, FIV and/or heartworm disease?
Are there other pets in the household No Yes How many and what kind(s)?
Where does pet stay when family is away from home?
Does or has pet pet travel(ed)? No/Yes Where:
What veterinary insurance plan are you using? None/Embrace/Nationwide/Trupanion/VPI/Other
What daily dental care regime are you following? Brushing/Dental wipes/Dental chews/Water additive/dental diet/None
If condition present, please either describe; classify as mild, moderate or severe; or classify on customary
scale
**CIRCULATORY**
Normal rate: Present/Absent
Normal rhythm: Present/Absent
Synchronous pulses: Present/Absent
Murmur: Present/Absent Grade 1/Grade 2/Grade 3/Grade 4/PMI:
Other:
**RESPIRATORY SYSTEM**
Normal BV (lung) sounds: Present/Absent
Nasal discharge: Present/Absent
Coughing: Present/Absent
Crackles/wheezes: Present/Absent
Other:
**ORAL CAVITY**
Moist mucous membranes of normal color and capillary refill time: Present/Absent
Halitosis ("bad breath"): Present/Absent
Gingivitis Mild Moderate: Severe/Absent
Calculus: 0/1/2/3/4
Missing dentition: Absent/Present Site:
Worn/fractured dentition: Absent/Present Site:
Oral masses, inflammation, ulceration or abnormal pigmentation Absent/Present Site:
Lesion(s) of tongue, hard palate, soft palate: Absent/Present Site:
Foreign body: Absent/Present Site:
Other:
**EYES**
Menace (inconsistently present in cats): Left present/Left absent/Right present/Right absent
Positive direct and consensual PLRs: Left present/Left absent/Right present/Right absent
Lid lesions: Left present/Left absent/Right present/Right absent
Discharge: Left present/Left absent/Right present/Right absent
Conjunctival lesion(s): Left present/Left absent/Right present/Right absent
Corneal lesion(s): Left present/Left absent/Right present/Right absent
Nuclear sclerosis :Left present/Left absent/Right present/Right absent
Cataract or lesion(s) of lens: Left present/Left absent/Right present/Right absent
Anterior segment lesion(s): Left present/Left absent/Right present/Right absent
Lesion(s) of fundus: Left present/Left absent/Right present/Right absent
Fluorescein stain: Left positive/Left negative/Right positive/Right negative
Other:
**EARS**
Pinna lesion(s): Left present/Left absent/Right present/Right absent
Odor: Left present/Left absent/Right present/Right absent
Discharge: Left present/Left absent/Right present/Right absent
Inflammation canals: Left present/Left absent/Right present/Right absent
Visible tympanic membrane(ear drum): Left present/Left absent/Right present/Right absent
Other:
**Cytology**: No Microorganisms
Yeast:
AS( left): 1+/2+/3+
AD (right): 1+/2+/3+
Cocci Bacteria:
AS( left): 1+/2+/3+
AD (right): 1+/2+/3+
Rod Bacteria:
AS( left): 1+/2+/3+
AD (right): 1+/2+/3+
**ABDOMEN**
Distension: Present/Absent
Organomegaly: Present/Absent
Mass(es): Present/Absent
Appropriate bowel wall thickness: Present/Absent
Other:
**UROGENITAL**
Normal shape and size of kidneys if palpable: Present/Absent
Palpation of urinary bladder concerning for stones or bladder wall thickening: Present/Absent
Normal conformation of external genitalia: Present/Absent
Mammary masses: Present/Absent
Other:
**RECTUM**
Mass(es) of rectum and/or urethra: Present/Absent
Normal size and position of pelvic canal: Present/Absent
Anal sac distension / disease: Present/Absent
Anal sacs expressed: Left/Right
Digital rectal examination not performed, but external palpation unremarkable:
Other:
**MUSCULAR SYSTEM**
Lameness: Present/Absent
Normal gait and posture: Present/Absent
Pain: Present/Absent
Other:
**LYMPH NODES**
Lymph node enlargement: Present/Absent
Site of enlargement(s) if present
**NERVOUS SYSTEM**
Appropriate mental status and behavior: Present/Absent
Normal strength, symmetry and coordination: Present/Absent
Normal placement: Present/Absent
Normal cranial nerves (if performed): Present/Absent
Normal spinal reflexes (if performed): Present/Absent
Other:
**SKIN**
Odor: Present/Absent
Hairloss: Present/Absent Site:
Seborrhea (flaking): Present/Absent Site:
Fleas: Present/Absent
Ticks: Present/Absent
Subcutaneous/cutaneous masses : Present/Absent Site:
Papules: Present/Absent Site:
Pustules: Present/Absent Site:
Epidermal collarettes: Present/Absent Site:
Erythema: Present/Absent Site:
Pruritus (itching) scale: Site :
Other:
**Cytology**: No Microorganisms
Yeast:
Site: Grade: 1+/2+/3+
Site: Grade: 1+/2+/3+
Cocci Bacteria:
Site: Grade: 1+/2+/3+
Site: Grade: 1+/2+/3+
Rod Bacteria:
Site: Grade: 1+/2+/3+
Site: Grade: 1+/2+/3+
**Scrape:**
**DIAGNOSTICS**
Fecal centrifugation /float: No ova or parasites/Parasites/ Recommended, but declined
Fecal cytology: Normal/Abnormal/Recommended, but declined
Fecal collection cup sent home:
Fecal Dx to lab pending - we will email results once they are available:
FELV: Negative/Positive
FIV: Negative/Positive
Feline heartworm: Not detectable/Positive/Recommended, but declined
Complete blood cell count: All values within normal reference ranges/Values outside of normal reference ranges/Recommended, but declined/Basic panel to lab pending
Serum chemistry panel All values within normal reference ranges/Values outside of normal reference ranges/Recommended, but declined/Basic panel to lab pending - we will email results once they are available
Urinalysis: Normal/Abnormality(ies) / notes: /pending/ Recommended, but declined
Feline pancreatic lipase: Normal (pancreatitis highly unlikely)/Abnormal (consistent with possible pancreatitis)
Radiographs: Normal/Findings: /Recommended, but declined
T4: Low/Normal/High
Pending tests:
Other:
**VACCINATIONS** Site Declined
FVRCP: #1/#2/#3/Triennial Due again: at 6 months/3 years , Site: right forelimb ,Declined:
Rabies: yes/No. Due again: 1 year, Site: RIGHT hindlimb, Declined:
Feline leukemia #1/#2 Due again: 1 year/2 years Site: LEFT hindlimb
Declined vaccinations: Feline leukemia (indoor only/minimal risk)
**TENTATIVE OR DEFINITIVE DIAGNOSES:**
**INSTRUCTIONS/RECOMMENDATIONS:**
Please take advantage of our comprehensive oral health assessment and treatment recommendation plan which
includes anesthesia and electronic anesthesia monitoring, IV catheter placement and fluids during procedure,
full-mouth x-rays, dental scaling, sub-gingival curettage (cleaning below the gumline just as our dentist does
for us) and dental polishing. Dental/periodontal disease is the most commonly diagnosed disease in cats,
affecting 75% of feline patients over the age of 2 years. Oral disease can affect overall health, so routine
assessment and preventative care is absolutely essential!
Daily dental care (brushing preferred, Feline Greenies, Healthy Mouth Rinse (www.healthymouth.com), other VOHC approved oral care products)
Continue monthly parasite protection (heartworm disease, fleas/ticks, intestinal parasites)...even indoor only cats can acquire heartworms...and fleas can carry potentially fatal disease(s)! Monthly Revolution is
imperative for your pet's overall health!
Specific food recommendation:
**TREATMENTS/PROCEDURES:**
**PRESCRIPTIONS** (all instructions clearly printed on labels):
**NEXT EXAM:**
Adult Feline Wellness
**Consultation history:**
Date:
**POST APPOINTMENT INSTRUCTIONS:**
Meds:
Recheck:
Other notes (dc notes, bill, food, etc):
RTG?:
**History:** Routine examination for vaccinations. Doing well at home. Eating and drinking normally. No owner or patient concerns. Good E level/appetite. No v/d/c/s. Normal urine/thirst/feces. **Staff initials:**
**Anal gland expression?**
**Nail trim?**
**Current meds/deworming:**
**Current diet (grain-inclusive? legume-free?):**
**Temperature:**. C (aural)
**Pulse:** bpm
**Respiration:** brpm
**Body Condition Score:** BCS 5/9
**Attitude:** BAR, friendly
**Oral cavity/MMs:** MMs pink, moist, CRT<2 sec
**Teeth:** NSF
**Cardiovascular:** No murmur or arrhythmia auscultated
**Respiration:** Clear in all fields, no crackles or wheezes
**Lymph nodes:** Peripheral lymph nodes normal size and symmetrical
**Eyes:** Clear
**Ears:** Clean
**Nasal:** NSF
**Abdominal Palpation:** Soft and comfortable throughout
**Musculoskeletal:** NSF
**Genitourinary:** NSF
**Integumentary:** NSF
**Rectal:** NSF
**Nervous:** NSF
**Diagnostics:**
**CBC:** n/a
**CHEM/LYTES:** n/a
**Radiographs:** n/a
**Cytology:** n/a
**Vaccinations:**
FVRCP LH SQ @ stifle (Purevax serial #, expiration: ) - **repeat in 1 year/ 3 years**
FeLV LF SQ @ elbow (Purevax serial #, expiration:) - **repeat in 1 year**
Rabies RH SQ @ stifle (Defensor3 serial #, expiration:) - **repeat in 1 year/3 years**
**Treatment Plan/ Recommendations/ Medications to go home:**
Discussed PE findings and potential vx reactions; no vx 100% protective
Recommend deworming
Recommend grain inclusive, low legume based diet.
Recommend flea/tick prevention, Recommend heartworm prevention
Equine Templates
Equine SOAP
**Date:**
**Veterinarian:**
**Charges:**
**Owner:**
**Alternate Contact:**
**Animal Identification:**
**History/Previous Treatment:**
**Presenting Complaint:**
**Physical Examination:**
T: (F/C) HR: bpm RR: /min
Attitude: BCS:
Appetite: Normal/Partial/Absent Duration:
**Significant Findings:**
**Assessment:**
**Treatment Plan:**
**Instructions to Owner:**
1- Product:
Amount:
Route:
Frequency:
Duration:
2- Product:
Amount:
Route:
Frequency:
Duration:
**Withdrawal Instructions:**
Date:
Veterinarian's Signature:
Equine Dentistry
**[History]**
-Previous dental issues:
-Current symptoms:
-Feeding habits:
-Problems with bit:
**[Physical Exam]**
-General appearance:
-Jaw alignment:
-TMJ palpation:
-Head palpation:
-Bars palpation:
-Presence of cheek ulcers:
-Central Incisor (101):
-Intermediate Incisor (102):
-Corner Incisor (103):
-Canine (104):
-Wolf Tooth (Premolar 1, if present) (105):
-Premolar 2 (106):
-Premolar 3 (107):
-Premolar 4 (108):
-Molar 1 (109):
-Molar 2 (110):
-Molar 3 (111):
-Central Incisor (201):
-Intermediate Incisor (202):
-Corner Incisor (203):
-Canine (204):
-Wolf Tooth (Premolar 1, if present) (205):
-Premolar 2 (206):
-Premolar 3 (207):
-Premolar 4 (208):
-Molar 1 (209):
-Molar 2 (210):
-Molar 3 (211):
-Central Incisor (301):
-Intermediate Incisor (302):
-Corner Incisor (303):
-Canine (304):
-Premolar 2 (306):
-Premolar 3 (307):
-Premolar 4 (308):
-Molar 1 (309):
-Molar 2 (310):
-Molar 3 (311):
-Central Incisor (401):
-Intermediate Incisor (402):
-Corner Incisor (403):
-Canine (404):
-Premolar 2 (406):
-Premolar 3 (407):
-Premolar 4 (408):
-Molar 1 (409):
-Molar 2 (410):
-Molar 3 (411):
-Diastema:
**[Diagnostic Tests]**
-Radiographs:
-Other tests:
**[Procedures]**
-Sedation:
-Extractions:
-Other procedures:
**[Treatment Plan]:**
-Medications prescribed:
-Follow-up appointments:
-Dietary recommendations:
Avian Templates
Avian Exotic Template I
**Chief Complaint:**
- Reason for visit
**History:**
- Detailed history of the presenting complaint
- Previous medical history
- Diet
- Environment
- Behavior
**Physical Examination:**
- General appearance
- Weight
- Body condition score
- Feather condition
- Behavior/neurological status
- Eyes, ears, nose, throat
- Beak, oral cavity
- Skin/feathers
- Musculoskeletal system
- Cardiovascular system
- Respiratory system
- Gastrointestinal system
- Urogenital system
- Cloaca
**Diagnostic Tests:**
- Test name and result
- Additional tests if needed
**Assessment:**
- Summary of findings
- Differential diagnoses
**Plan:**
- Treatment plan
- Any prescribed medications
- Client education
- Follow-up appointments
**Notes:**
- Any additional observations or plans
Physical Examination:
- General appearance
- Weight
- Body condition score
- Feather condition
- Behavior/neurological status
- Eyes, ears, nose, throat
- Beak, oral cavity
- Skin/feathers
- Musculoskeletal system
- Cardiovascular system
- Respiratory system
- Gastrointestinal system
- Urogenital system
- Cloaca
**Diagnostic Tests:**
- Test name and result
- Additional tests if needed
**Assessment:**
- Summary of findings
- Differential diagnoses
**Plan:**
- Treatment plan
- Any prescribed medications
- Client education
- Follow-up appointments
**Notes:**
- Any additional observations or plans
Avian Exotic Template II
**Avian Background Information:**
Code Status:
Is this a referral?: Regular DVM / Hospital:
Pet Insurance: Is the patient protected by an insurance plan?:
How old is your home?:
Do you use any cleaners/sprays/candles/Teflon products/non-stick cookware/ or cook around the patient?:
Other birds in the house?:
Other pets in the house?:
Behavior: Has the patient had any aggression- or fear-based incidents in the past?:
Does he/she go outdoors at all?:
Does he/she live in an enclosure?:
What kind of substrate/bedding is used if any?:
Do you use a UVB Bulb? What type? Distance from the pet?:
How often is the UVB bulb changed?:
Diet:
Eating/drinking normally?:
Any supplements used?:
Brand? Type:
Normal droppings/normal amount?:
Sneezing, Vomiting or Regurgitation?:
Is your pet lethargic or quiet?:
Behavior normal? Perching? Active?:
Flighted?:
If a Female-Does the patient lay eggs?:
Is your pet on any medications?:
Adverse Medication / Reactions:
When were the last doses administered?:
Are any refills needed today?:
**Attending Veterinarian:**
**Presenting complaint and duration:**
**Current History:**
**Previous Medical History:**
Husbandry changes discussed:
Husbandry changes recommended today:
**Objective:**
Vital Signs:
Heartrate:
Respiration:
Weight: Previous weight: (kg)/ Date:
Flighted:
Mentation:
Characterize Droppings:
Perching normal position:
Nurse:
**Examination Findings:**
Body Condition Score: /5
Muscle Condition Score: /3
Pain Scale: 0/4
ASA: 0-4
Eyes, Ears, Nose, Throat: Fundic normal OU, normal cornea, lenses and iris OU; Clear AU; Nares clear bilaterally, no discharge or lesions
Oropharyngeal: Normal beak occlusion, normal keratin, no lesions or defects; normal tongue; choana clear with normal/ABNORMAL choana papillae, mm pink/pigment and moist
Cardiovascular: normal rate and rhythm, normal ulnar refill and volume
Respiratory: Normal RR/RE, clear on auscultation over dorsum/lungs, air sacs clear in all fields, no rubbing or fluid noted
Abdomen / GI: Soft concave coelom, no masses or lesions palpable
Vent Exam: mucosa clear on eversion, pink moist, no polyps or lesions; normal perivent
Urogenital: normal urates, Sex UNKNOWN/MALE/FEMALE
Musculoskeletal: normal wing snap, normal grip strength, normal/ABNORMAL keel muscle condition
Integumentary: NORMAL/ABNORMAL feather quality, normal skin of face, head and pes, normal nails
Nervous System: normal perch position, normal posture, no weakness of pelvic or thoracic limbs
Behavior: N/A
**Labs + Diagnostics:**
**Assessment:**
**Current Assessment/Differentials:**
**Chronic health concerns:**
**Prognosis:**
**Historical Problem list/Visits:**
**Plan:**
**Medications:**
Other Animals
Farm Animal SOAP
**Date:**
**Veterinarian:**
**Charges:**
**Owner:**
**Alternate Contact:**
**Animal Identification:**
**History/Previous Treatment:**
**Presenting Complaint:**
**Physical Examination:**
T: (F/C) HR: bpm RR: /min
Weight/Body Condition:
Attitude: BCS:
Appetite: Normal/Partial/Absent Duration:
Reproductive Status: Pregnant/Open/Fresh/Bred/Immature
**Significant Findings:**
**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 .
Date:
Veterinarian:
Reptile SOAP
History:
Code Status:
Is this a referral?
Pet Insurance: Is the patient protected by an insurance plan?:
How old is your home?:
Do you use any cleaners/sprays or other chemicals around the patient?:
Other reptiles in the house?:
Other pets in the house?:
Behavior: Has the patient had any aggression- or fear-based incidents in the past?:
Does he/she go outdoors at all?:
Does he/she live in an enclosure?:
What kind of substrate/bedding is used?:
Do you use a UVB Bulb? What type? Distance from the pet?:
How often is the UVB bulb changed?:
What is the temperature in the cage?
How is this monitored?:
High Temp:
Low Temp:
What is the humidity in the cage?
How is this monitored?:
Diet:
Eating/drinking normally?:
Any calcium/vitamin supplements used?:
Brand? Type:
Normal droppings/normal amount?:
Sneezing, Vomiting or Regurgitation?:
Is your pet lethargic or quiet?:
Behavior normal?:
If Female-Has the patient laid eggs or given birth ?:
When was your reptile's last shed? Was it normal?:
Is your pet on any medications?:
Adverse Medication / Reactions:
When were the last doses administered?:
Are any refills needed today?:
Attending Veterinarian:
Presenting complaint and duration:
Current History:
Any previous health issues?:
Previous Medical History:
Husbandry changes discussed:
Husbandry changes recommended today:
Nurse/Date:
Objective:
Heartrate:
Respiration:
Weight: Previous weight (kg)/ Date:
Mentation:
Characterize Feces:
Normal body positioning/strength:
Hydration Status:
Nurse:
Examination Findings:
Body Condition Score: /5
Muscle Condition Score: /3
Pain Scale: 0/4
ASA: 0-4
Eyes, Ears, Nose, Throat: normal corneas OU, normal fundic OU, no periocular swelling or lesions OU; Tympanum normal and intact AU, no bulging or discharge; Nares normal bilaterally, no discoloration or discharge; No neck or swelling or masses noted.
Oropharyngeal: Pink/PIGMENTED moist mucous membranes; Saliva curtain THICK/ABSENT; No/hypersalivation present; No masses or lesions within other oropharynx, no plaques; No obvious aneurysms noted, no tissue swelling. Beak is Normal/ABNORMAL.
Cardiovascular: normal on Doppler
Respiratory: Normal RR/RE, no open mouth breathing, no discharge, no distress or accessory muscle breathing noted. Recovered quickly after handling.
Abdomen / GI: Coelomic palpation is normal/ABNORMAL; No masses or lesions palpable; Normal/ABNORMAL material passed on defecation; Vent is pink/PIGMENTED, moist with no lesions or masses.
Vent Exam: Pink/Pigmented mucosal on eversion, no masses or lesions; NO/Hemipenal plugs noted. No substrates noted within the vent.
Urogenital: Urates/urine normal/ABNORMAL/not observed during exam; FEMALE/MALE/SEX UNKNOWN
Musculoskeletal: Normal strength, ambulates normally/ABNORMALLY; Normal grip/elevation of body from surfaces, no weakness.
Integumentary: Normal/ABNORMAL carapace and plastron, no pitting/ulceration noted; No/retained shed or thermal burns, bite wounds or other dermal lesions; Normal/ABNORMAL scales
Nervous System: Mentally appropriate, normal pain perception, normal ambulation
Other: N/A
Behavior: N/A
Labs + Diagnostics:
Assessment:
Current Assessment/Differentials:
Chronic health concerns:
Prognosis:
Historical Problem list/Visits:
Plan:
Therapeutic Plan:
Medications:
Meds Filled/Nurse [ n/a ]
Meta-Plan:
Small Mammal SOAP
Subjective:
History:
Small Mammal Background Information:
Code Status:
Is this a referral?:
Pet Insurance: Is the patient protected by an insurance plan?:
How old is your home?:
Other pets in the house?:
Behavior: Has the patient had any aggression- or fear-based incidents in the past?:
Does he/she go outdoors at all?:
Does he/she live in an enclosure?:
What kind of substrate/bedding is used?:
What is the temperature in the cage (Hedgehogs)?
How is this monitored?:
Diet:
Eating/drinking normally?:
Any supplements used?:
Brand? Type:
Normal droppings/normal amount?:
Coughing, Sneezing, Nasal Discharge?:
Vomiting (Ferrets only):
Is your pet lethargic or quiet?:
Behavior normal?:
Is your pet on any medications?:
When were the last doses administered?:
Adverse Medication / Reactions:
Are any refills needed today?:
Attending Veterinarian:
Presenting complaint and duration:
Current History:
Any previous health issues?:
Previous Medical History:
Husbandry changes discussed:
Husbandry changes recommended today:
Nurse/Date:
Objective:
Vital Signs:
Heartrate:
Respiration:
Capillary Refill Time:
Temperature:
Weight: Previous weight (kg)/ Date:
Mentation:
Characterize Feces/Fecal Pellets:
Hydration status:
Nurse:
Labs + Diagnostics :
Assessment:
Current Assessment/Differentials:
Chronic health concerns:
Prognosis:
Historical Problem list/Visits:
Plan:
Therapeutic Plan:
Medications:
Meds Filled/Nurse
Meta-Plan: