Veterinary Medical Evaluation Page 2
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2Are you or the owner aware of any current medical problems?
______________________________________________________________________________
______________________________________________________________________________
Recently noticed:
Diarrhea ___
Scratching ___
Vomiting ___
Lethargy ___
Frequent urination ___ Coughing ___
Sneezing ___
Open sores ___
External parasites ___ Anorexia ___
Runny eyes ___
Runny nose ___
Please examine the following: (make any comments you deem necessary)
Normal Abnormal
Comments
___
___
General condition/cleanliness ____________________________________________
___
___
Nails ______________________________________________________________
___
___
Coat ______________________________________________________________
___
___
Integument _________________________________________________________
___
___
Ears ______________________________________________________________
___
___
Eyes ______________________________________________________________
___
___
Nose _____________________________________________________________
___
___
Oral cavity _________________________________________________________
___
___
Lymph nodes _______________________________________________________
___
___
Urogenital _________________________________________________________
___
___
Auscultation ________________________________________________________
___
___
Abdominal Palpation __________________________________________________
___
___
Temperature ________________________________________________________
Additional comments:
______________________________________________________________________________
______________________________________________________________________________
Do you feel that this dog should participate in Therapy Dog Services in healthcare facilities
(keeping in mind the health of the dog, hospital patients and staff)?
Yes_____________________
No_______________________
Yes, with the following concerns addressed:
______________________________________________________________________________
______________________________________________________________________________
Veterinarian’s name (Please print):___________________________________
Veterinarian’s signature: __________________________________ Date: _________________
Please fax this report to the Good Dog office at (888) 861-7312 and keep a copy of this
report for your records. If you cannot fax this form, please mail it to: The Good Dog Foundation,
PO Box 1484, New York, NY 10276. Please do not both fax and mail this form.
| PO Box 1484 | New York, NY 10276 | (888) 859-9992 | Fax (888) 861-7312
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