1.  Coat & Skin

7.  Heart

□ Appear Normal

□ Pigment

□ Itchy

□ Sounds Normal

□ Arrhythmia

□ Dry/Dull

□ Lesion

□ Malted

□ Murmur

□ Other ____________________

□ Greasy

□ Lumps

□ Shedding

8.  Abdomen

□ Scaly

□ Parasites

□ Hair Loss

□   Appears Normal

Other________________

2.  Eyes

[ ] Fluid / Mass

 Appear Normal

□ Retina:  L___  R___

□ Discharge:  L___  R___

□ Ulcers/Lesions:  L___  R___

□ Inflamed:  L___  R___

□ Eyelid Adenoma

9.  Lungs

□ Infection:  L___  R___

□ Other ___________________

□ Sound Normal

□ Other _____________________

□ Cataract:  L___  R___

□ Abnormal Sound

____________________________

3.  Ears

□ Coughing

□ Appear Normal

□ Excessive debris L___  R___

□ Congestion

□ Inflamed:  L___  R___

□ Itchy

10.  Urogenital System

□ Yeast Inf.:  L___  R___

□ Other __________________

□ Appears Normal

□ Mammary Tumors

□ Bacterial Inf.:  L___ R___

_________________________

□ Abnormal Urination

□ Anal Sac Tumor Check

4.  Lymph Nodes

[ ]Prostate

□  Normal/Enlarged

5.  Mouth, Teeth, Gums

11.  Weight __________ lbs.

□ Appear Normal

□ Gingivitis (inflamed Gums)

□ Normal Range

□ Underweight

□ Broken Tooth/Teeth

□ Ulcers/Lesions

□ Overweight approx ____ lbs

Other ______________________

□ Loose Tooth/Teeth

□ Pyorrhea (pus)

Microchipped ?

□ Tarter  _____ major  _____moderate   ______minor

□ Yes

□ For your pet’s health’s sake a dental cleaning needs to be done as            soon as you can schedule it.

□ No

□ A teeth cleaning should be done within _____ to _____ months

Water Consumption Normal?

□ A teeth cleaning is not needed at this time.

□ Yes

6.  Musculoskeletal

□ No

□ Appears Normal

Normal Urination and BM?   Yes □        No □

□ Mobility Issues Y□  N□

Cognitive Function Change?   Yes □        No □

□ Pain on palpation

□ Stiffness