Prairie State Veterinary Clinic
100 Ravinia Place
Orland Park, Illinois 60462
708-349-3331
Comprehensive Health Exam Report
Pet: __________________________________________ Date: ______________
[ ] Physical Exam:
1. Coat & Skin
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7. Heart
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□ Appear Normal
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□ Pigment
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□ Itchy
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□ Sounds Normal
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□ Arrhythmia
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□ Dry/Dull
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□ Lesion
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□ Malted
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□ Murmur
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□ Other ____________________
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□ Greasy
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□ Lumps
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□ Shedding
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8. Abdomen
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□ Scaly
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□ Parasites
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□ Hair Loss
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□ Appears Normal
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Other________________
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2. Eyes
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[ ] Fluid / Mass
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Appear Normal
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□ Retina: L___ R___
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□ Discharge: L___ R___
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□ Ulcers/Lesions: L___ R___
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□ Inflamed: L___ R___
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□ Eyelid Adenoma
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9. Lungs
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□ Infection: L___ R___
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□ Other ___________________
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□ Sound Normal
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□ Other _____________________
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□ Cataract: L___ R___
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□ Abnormal Sound
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____________________________
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3. Ears
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□ Coughing
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□ Appear Normal
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□ Excessive debris L___ R___
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□ Congestion
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□ Inflamed: L___ R___
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□ Itchy
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10. Urogenital System
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□ Yeast Inf.: L___ R___
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□ Other __________________
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□ Appears Normal
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□ Mammary Tumors
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□ Bacterial Inf.: L___ R___
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_________________________
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□ Abnormal Urination
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□ Anal Sac Tumor Check
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4. Lymph Nodes
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[ ]Prostate
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□ Normal/Enlarged
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5. Mouth, Teeth, Gums
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11. Weight __________ lbs.
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□ Appear Normal
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□ Gingivitis (inflamed Gums)
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□ Normal Range
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□ Underweight
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□ Broken Tooth/Teeth
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□ Ulcers/Lesions
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□ Overweight approx ____ lbs
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Other ______________________
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□ Loose Tooth/Teeth
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□ Pyorrhea (pus)
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Microchipped ?
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□ Tarter _____ major _____moderate ______minor
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□ Yes
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□ For your pet’s health’s sake a dental cleaning needs to be done as soon as you can schedule it.
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□ No
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□ A teeth cleaning should be done within _____ to _____ months
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Water Consumption Normal?
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□ A teeth cleaning is not needed at this time.
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□ Yes
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6. Musculoskeletal
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□ No
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□ Appears Normal
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Normal Urination and BM? Yes □ No □
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□ Mobility Issues Y□ N□
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Cognitive Function Change? Yes □ No □
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□ Pain on palpation
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□ Stiffness
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[ ] Complete Blood Count: See Attached Report and Comments.
[ ] Metabolic Profile: See Attached Report and Comments.
[ ] Thyroid Hormone Level: [ ] Normal [ ] Abnormal [ ] Canine Basal Cortisol Level: [ ] Normal [ ] Abnormal
[ ] Complete Urinalysis: [ ] Normal [ ] Abnormal
[ ] Blood Pressure: __________ [ ] Normal [ ] Abnormal
[ ] Intestinal Parasite Exam [ ] Neg [ ] Pos ] Giardia: [ ] Neg [ ] Pos
[ ] Canine Arthropod Screen: Heartworm: [ ] Neg [ ] Pos Lyme: [ ] Neg [ ] Pos
Anaplasma: [ ] Neg[ ] Pos Ehrlichia: [ ] Neg [ ] Pos
[ ] Feline Leukemia Virus: [ ] Neg [ ] Pos Feline Aids Virus: [ ] Neg [ ] Pos
[ ] Chest X-Ray: [ ] Normal [ ] Abnormal (see attached report)
[ ] Electrocardiogram: [ ] Normal [ ] Abnormal (see attached report)
[ ] Nail Trim and Ear Cleaning [ ] 25% Discount of a dental cleaning within 1 year
[ ] Written Report & Recommendations
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