Annual Health Evaluation
Urban Search & Rescue Canine
Handler ________________________ Veterinarian __________________________
Task Force________________________
Hospital ___________________________
Address ________________________
Address ___________________________
________________________
___________________________
Contact # ________________________
Contact #___________________________
Canine ________________________
Breed
________________________
Color
________________________
Birth Date ________________________
Sex
M MN F FS
Weight
________kg ________lb
PHYSICAL EXAMINATION
Attitude
Hydration
MM/CRT
Eyes
Ears
Nose
Throat
U/G F: Mammary Glands
Vulva
Rectal
Integ: Coat, Dermis
M/S: Body Condition
Orthopedic
Neurologic
Date of Exam_______________________
Temperature
Heart Rate, Rhythm
Pulses
Respiration Rate/Sound
Lungs
Peripheral Lymph Node
Abdomen Palpate
Male: Prepuce/Penis
Scrotum/Testicles
Anal Tone/Sacs
Pads, Nails
Gait
______
CURRENT ISSUES? (coughing, sneezing, vomiting, diarrhea, lethargy, anorexia, depression,
PU, PD, PP?) ___________________________________________________________________
______________________________________________________________________________
ADDITIONAL NOTES ON ANY ABNORMAL FINDINGS
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VACCINATIONS – Core
VACCINE
TYPE
K9 Parvovirus_
K9 Distemper Virus
K9 Adenovirus-2
Rabies (Killed)
VACCINATIONS - Optional
VACCINE
TYPE
Parainfluenza Virus
Bordetella bronch
Borrelia burgdorferi
Leptospirosis
TESTS
Heartworm Check
Tick-borne Diseases
CBC
Biochemical Profile
Other ___________
___________
 Pos  Neg
 Pos  Neg
 N  Abn
 N  Abn
 N  Abn
 N  Abn
Annual/Biennial/Triennial
DATE GIVEN__
__________________
______
__________________
Annual/Biennial/Triennial
DATE GIVEN__
__________________
______
__________________
 N/A
 N/A
 N/A
 N/A
Fecal
Urinalysis
ECG
Radiographs
Ultrasound
N
N
N
N
N
 Abn
 Abn
 Abn
 Abn
 Abn
 N/A
 N/A
 N/A
 N/A
 N/A
For abnormal or positive, please provide a brief summary on treatment and follow-up if
deemed necessary. Test copies or record copies are fine for more extensive information.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Was sedation or other restraint used to perform exam or tests? No  Yes___________
CURRENT MEDICATIONS
Heartworm Preventative:
Drug_____________
Flea/Tick Preventative:
Drug_____________
Other: Drug_____________
Drug_____________
HISTORICAL DATA
We have asked the handler to relate both historical and current conditions that his or her
canine may have experienced. Any information regarding a condition (diagnostics,
treatments, acute vs chronic vs recurrent nature, medications, etc…) is appreciated.
(extensive histories can be copied from prior forms)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Thank you for your time.
Veterinarian’s Signature_______________________ Date______________________
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