Evaluation Form for Transport Animals Requiring a Health ...
CanINE Express Transport Project
Evaluation Form for Transport Dogs/Puppies Requiring a
Health Certificate for Interstate Transport
Veterinarian Performing Evaluation: ________________________________________________
Date and Time of Evaluation: ______________________________________________________
Dog/Puppy’s Temperature: _________________° F Age: __________________________
Dog/Puppy Name: ___________________________________________ Sex: _______________
Breed: _______________________________________ Weight: _______lbs. _________oz.
1. Observe the dog’s//puppy’s attitude and alertness, movement size, and shape. Circle unusual activities:
headshaking scratching limping
vomiting tremors
other: __________________________________________________________________
2. Listen and circle any of the following that exist:
coughing sneezing difficulty breathing
gagging wheezing
other: __________________________________________________________________
3. Look at the dog’s face and circle any of the following potential problems:
L. EYE: discharge redness cloudy third eyelid up hair loss or redness on skin
R, EYE: discharge redness cloudy third eyelid up hair loss or redness on skin
NOSE: discharge crusty foreign material
L. EAR: inside: redness discharge odor dirty
outside: redness swelling hair loss
R. EAR: inside: redness discharge odor dirty
outside: redness swelling hair loss
MOUTH: bite discharge abnormal gum color crust or scabs at corners
4. Examine the dog’s head, neck, back, body, belly, and tail (including between the legs and
beneath the tail) and note the following:
Redness where: ___________________________________________
Hair loss where: ___________________________________________
Foreign material where: ___________________________________________
Wetness where: ___________________________________________
Dryness where: ___________________________________________
Oiliness where: ___________________________________________
Sores where: ___________________________________________
Scabs where: ___________________________________________
Scaliness where: ___________________________________________
Discoloration where: ___________________________________________
5. Record any other observations or concerns, such as signs of dehydration, discomfort, or hotness.
6. Record any observations or concerns with overall physical appearance of the dog/puppy such as possible hip dysplasia, need for cruciate surgery, gunshot wound, etc.
Signature of Veterinarian Performing Examination Date
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