Veterinary Medical Record

I. PATIENT INFORMATION

Field	Details
Animal Name	Bella
Species	Dog
Breed	Labrador Retriever
Age/DOB	5 years / 03-14-2084
Gender	Female (Spayed)
Color/Markings	Yellow, white patch on chest

II. OWNER INFORMATION

Field	Details
Owner's Name	Naomi Ortiz
Address	Irving, TX 75038
Phone Number	222 555 7777
Email	naomi@you.mail

III. PRESENTING PROBLEM

Annual wellness checkup and vaccination updates.

IV. MEDICAL HISTORY

• Last visit: March 2088 (Routine check-up, no abnormalities).

• Fully vaccinated.

• Spayed at 6 months old.

• No known allergies.

• Mild seasonal itching treated with antihistamines (last occurrence: Spring 2088).

V. PHYSICAL EXAMINATION

System	Findings
General Appearance	Alert and active; healthy weight (25 kg).
Skin/Coat	Shiny and smooth; no lesions.
Eyes	Clear, no discharge.
Ears	Clean; no redness or odor.
Mouth/Teeth	Mild tartar on molars; no gum redness.
Heart/Lungs	Normal heart rate and respiration; no murmurs or crackles.
Abdomen	Soft, no masses detected.
Musculoskeletal	Normal range of motion; no lameness.
Neurological	Normal reflexes and responses.

VI. DIAGNOSTIC TESTS

Test Performed	Results
Fecal Exam	Negative for parasites.
Heartworm Test	Negative.

VII. ASSESSMENT/DIAGNOSIS

Healthy adult Labrador Retriever presenting for routine care.

VIII. TREATMENT PLAN

Treatment	Details
DA2PP Vaccination	Administered subcutaneously; booster due March 2090.
Rabies Vaccination	Administered subcutaneously; booster due March 2092.
Dental Care	Recommended dental cleaning within the next 6 months.

IX. FOLLOW-UP PLAN

• Schedule dental cleaning by September 2089.

• Next wellness visit: March 2090.

• Monitor for seasonal itching; administer antihistamines if necessary.

X. VETERINARIAN’S NOTES

Bella is in excellent health with no significant concerns at this time. Owner advised to maintain current diet and exercise routine.

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Veterinarian Name: [YOUR NAME]
License Number: 123456789
[YOUR COMPANY NAME]

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