VETERINARY ANIMAL HEALTH CHECKUP SURVEY CHECKLIST

Created by ChecklistGuro (https://checklistguro.com)

--- PATIENT DEMOGRAPHICS ---
[ ] Animal's Name
[ ] Animal's Breed
[ ] Animal's Age (Years)
[ ] Animal's Weight (lbs/kg)
[ ] Animal's Sex (Male, Female, Unknown)
[ ] Is Animal Spayed/Neutered? (Yes, No, Unknown)
[ ] Owner's Name
[ ] Owner's Phone Number

--- INITIAL OBSERVATION & HISTORY ---
[ ] Date of Last Visit
[ ] Reason for Visit (Owner's Perspective)
[ ] Current Medications? (Yes, No, Unsure)
[ ] History of Previous Illnesses/Surgeries
[ ] Estimated Age (if unknown)
[ ] Breed (if known) (Purebred, Mixed Breed, Unknown)

--- VITAL SIGNS ---
[ ] Temperature (Â°C)
[ ] Pulse Rate (bpm)
[ ] Respiratory Rate (breaths/min)
[ ] Weight (kg)
[ ] Time of Measurement
[ ] Measurement Technique (Rectal, Axillary, Ear)

--- PHYSICAL EXAMINATION - HEAD & NECK ---
[ ] Head Shape (Normal, Dolichocephalic, Brachycephalic)
[ ] Eyes - Symmetry (Symmetrical, Asymmetrical)
[ ] Eyes - Description of Findings (e.g., discharge, redness)
[ ] Nose - Discharge? (No, Yes, Serous, Mucopurulent)
[ ] Mouth - TPR (Temperature, Pulse, Respiration)
[ ] Oral Cavity - Description of Findings (e.g., gingivitis, ulcers)
[ ] Lymph Nodes - Palpable? (No, Yes)
[ ] Lymph Nodes - Description of Findings (size, consistency)

--- PHYSICAL EXAMINATION - THORAX & ABDOMEN ---
[ ] Heart Rate (bpm)
[ ] Heart Rhythm (Normal, Arrhythmic, Murmur Present (describe))
[ ] Respiratory Effort (Normal, Increased, Decreased, Labored)
[ ] Respiratory Rate (breaths/min)
[ ] Abdominal Palpation (Normal, Painful, Mass Detected (describe))
[ ] Abdominal Auscultation Notes

--- PHYSICAL EXAMINATION - MUSCULOSKELETAL ---
[ ] Weight (kg)
[ ] Gait Observation (Normal, Arboreal, Stiff, Limping (Right), Limping (Left))
[ ] Postural Assessment (Normal, Kyphosis, Swayback, Scoliosis)
[ ] Range of Motion (Shoulder - Degrees)
[ ] Range of Motion (Hip - Degrees)
[ ] Musculoskeletal Abnormalities (if any)

--- PHYSICAL EXAMINATION - SKIN & COAT ---
[ ] Coat Type (Short, Medium, Long, Wiry, Double)
[ ] Coat Condition (Excellent, Good, Fair, Poor)
[ ] Describe Coat Texture
[ ] Skin Lesions Present? (None, Papules, Pustules, Crusts, Scale, Erythema, Ulceration)
[ ] Number of Skin Lesions
[ ] Detailed Description of Skin Lesions (location, size, appearance)
[ ] Upload Skin Lesion Photos (if applicable)
[ ] Presence of Parasites? (No, Yes - Fleas, Yes - Ticks, Yes - Mites)

--- OPHTHALMOLOGICAL EXAMINATION ---
[ ] Pupil Size (Right) (Normal, Dilated, Mydriatic, Miosis, Unequal)
[ ] Pupil Size (Left) (Normal, Dilated, Mydriatic, Miosis, Unequal)
[ ] Pupillary Light Reflex (Right) (Present, Absent, Sluggish)
[ ] Pupillary Light Reflex (Left) (Present, Absent, Sluggish)
[ ] Visual Acuity (Right - if applicable)
[ ] Visual Acuity (Left - if applicable)
[ ] Ocular Abnormalities/Findings

--- AURAL EXAMINATION ---
[ ] Ear Canal Appearance (Normal, Mild Erythema, Moderate Erythema, Severe Erythema, Discharge Present)
[ ] Discharge Type (if present) (Serous, Purulent, Bloody, Unknown)
[ ] Cerumen (Earwax) Amount (Normal, Increased, Decreased)
[ ] Pinna Temperature (Â°C)
[ ] Additional Aural Exam Notes
[ ] Sensitivity to Palpation? (No, Mild, Moderate, Severe)

--- DIAGNOSTIC TESTS (IF APPLICABLE) ---
[ ] Bloodwork Requested? (Yes, No)
[ ] CBC - White Blood Cell Count (WBC)
[ ] Chemistry Panel - Glucose (mg/dL)
[ ] Urinalysis Requested? (Yes, No)
[ ] Radiology Notes (if applicable)
[ ] Fecal Exam Requested? (Yes, No)

--- TREATMENT PLAN & RECOMMENDATIONS ---
[ ] Detailed Treatment Protocol
[ ] Medication Dosage (mg)
[ ] Medication Route (Oral, Subcutaneous, Intramuscular, Topical)
[ ] First Medication Administration Date
[ ] Duration of Treatment (Days)
[ ] Follow-Up Appointment Type (Recheck Exam, Medication Review, Procedure Follow-Up)
[ ] Next Appointment Date

--- OWNER EDUCATION & FOLLOW-UP ---
[ ] Summary of Key Points Discussed with Owner
[ ] Next Appointment Date
[ ] Next Appointment Time
[ ] Medication Instructions Provided? (Yes, No)
[ ] Dietary Recommendations Provided? (Change in Food Type, Portion Control, Limited Ingredient Diet, None)
[ ] Follow-up Appointment Cost Estimate
[ ] Owner Understanding of Plan? (Fully Understands, Mostly Understands, Needs Further Explanation)
[ ] Additional Notes/Instructions for Owner

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