FOSTER DOG VETERINARY WELLNESS CHECK

Foster Home Name:

Address:

Phone:

Dog's Name:                                                           Age:                                      Sex:

Section 1:   General Health of the Dog

     

Vital Signs:

 

Medications:   

 

 

Pulse:

Respiration:

 

 

Temperature:

Weight:

 

Section 2:  General Systems Evaluation - Please list the findings and comments on any abnormal finding, e.g., heart is abnormal, dog has a systolic heart murmur.  Note any physical problems that might put the animal at risk, e.g., arthritis, painful ear infections, etc.
 

     

System

Normal

Abnormal

Findings/Comments

 

General Appearance

 

 

 

Skin/Coat

      

Muscuol-Sketetal

Heart/Lungs

Digestive

      

Urogenital

      

Eyes/Ears

      

Nervous

      

Lymph Nodes

      

Mucous Membranes

      

 Teeth/Mouth

 

 

 

 

Section 3:   Surgeries Performed

 

 


                                                               NO ACEPROMAZINE

 

Section 4:   Vaccinations

     

Vaccination

Expiration Date

Test

Result

 

Rabies (State Law)

 

 

 

 

 

DHLPP

 

 

 

 

 

 

 

 

Section 5:   Tests

 
 Date of Heartworm Exam: ___________________                         Results:  ___________________
 

     
Date of Fecal Exam:   ___________________                          Results:_______________________
 

 

Section 6:    Overall Assessment for Dogs

 

In your professional judgment, the overall health of this dog is:

      __Excellent (No serious chronic diseases or disorders)

 

      __Very good (Minor complaints associated with normal aging)

 

      __Good (Chronic conditions with occasional flare-ups)

 

      __Poor (Serious chronic condition requiring ongoing treatment)           

 

Please record additional comments or recommendations:

 

 

 

 

 

Name of Veterinary Practice:  ____________________________________________________________


Signature of DVM: ______________________________________________          Date: _____________

 

Address: ______________________________________________________     Phone:_______________

 

              ______________________________________________________

For Permission to perform additional services please call Gary at:  516-238-4730

Please fax this report to Boxer Angels Rescue at:  212-971-2592
and please give a copy of this report to the foster home for their records.

Mailing Address:  PO Box 543, North Bellmore, NY 11701