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