MEDICAL ASSESSMENT FORM
Please fill in the following information, by writing in the blanks, or checking the appropriate boxes or options.

RESPIRATORY:
(Normal respiration rate is 10-30 (kids 20-40) breaths per minute).

Breathing is normal
Breathing faster than normal 
Panting with shallow breaths 
Breathing sounds "raspy"
Excessive coughing
Increased respiration  only when animal has been active
Increased respiration  when animal is at rest as well as after activity
Approximately how many respirations per minute?



EYES:

  Clear
  Watery or Clear Discharge
  Yellow Discharge
  Cloudy/white
  Inside of eyelids appears pale

NOSE:

Clear, no mucus
Watery or Clear Discharge
Yellow Discharge
Discharge is thick
Discharge is thin

 SKIN  

No skin problems noted
Animal scratching 
Heavy dandruff
  Pimple-like sores
Lesions/sores
         Crusty
           Pus material
    Where are lesions/sores located?
    Face-Mouth-Head-Ears
    Feet-Legs
    Udder
    Anal Area
    Topline-flanks

STOOLS:

Normal 
Diarrhea-watery
Firmer than normal stools
Blood-streaked 
Yellowish
Greenish
Very dark
Mucous strings
"Frothy" stools
Segments of possible worms
Straining with passage of stools
Stools very foul smelling

VACCINATION/INJECTION HISTORY DATES: (Check if applicable) 

  Clostridium Yes  No (For overeating disease- enterotoxemia)  Date
  Tetanus Yes  No  (If using a product such as CDT vaccine, note this) Date
  Rabies   Yes No   Date
  Selenium  Yes  No  Date
 Other

HEALTH TESTING:

CAE   Test  Date Select One Within 30 days Within 6 months Within past year Never Test Results Select One Negative Positive Not Tested

JOHNES   Test  Date Select One Within 30 days Within 6 months Within past year Never Test Results Select One Negative Positive Not Tested

BRUCELLOSIS  Test  Date Select One Within 30 days Within 6 months Within past year Never Test Results Select One Negative Positive Not Tested

TUBERCULOSIS  Test  Date Select One Within 30 days Within 6 months Within past year Never Test Results Select One Negative Positive Not Tested

DEWORMING
Last date dewormed  Select One Within 30 days Within 6 months Within past year Never Unknown
What drug was used?
What amount was given?
What method of application? Select One Oral-by mouth Sub Q - Under Skin Topical - On skin

MANAGEMENT
Confined drylot (no pasture)
Pasture primarily
Hay  What kind?
Grain
Supplements Given (salt, type of minerals, etc.)

Has there been a recent change in diet? Yes  No

When?  
Describe the change  

Could animal have had access to any of the following (Check if applicable)

Poisonous plants   Specify  
Chemicals   Specify 
Moldy feed/hay 

Check any of the following SYMPTOMS:

Lethargic, depressed, reluctant to move
Down, and can't get up by itself
Crying excessively
Pawing the ground
Grinding Teeth
Arched Back
Abdomen distended (animal looks really "full")
If a ruminant, not chewing cud 
Tilting Head
Tremors/Shaking
Head pressing
Circling movements
Appears blind
Dry, stiff coat
Lame
Stiff, swollen joints  
Does not want to drink or eat
Will drink but not eat

When did you notice above symptoms?

If a female, is she lactating?   Yes  No   When did she freshen?  
If applicable, give details complications surrounding any birthing complications.
If pregnant, give date due:

  UDDER/MAMMARY 

Not applicable or no involvement
One side/half affected
Both sides/half affected
Hard Lumps
Soft Lumps
Abscesses
Lacerations/open wound
Blood in milk
Flecks of tissue in milk
Feels Hot
Feels Cold
Feels Hard

 If a BABY, check any of the following:

Nursing
Bottle Fed
Lambar/nipplebucket  Fed
Bowl Fed
Fed Milk Replacer
Fed Whole Goat Milk-Raw
Fed Whole Goat Milk - Pasteurized
Fed Cow Milk-Raw
Fed Cow Milk-Pasteurized
Warm milk or replacer
Cold milk or replacer

If weaned, when?

PLEASE NOTE ANY RECENT SURGERIES

None recently
Castration/band
Castration/cut
Castration/crush
Hornburning
Dehorning 

Other

Provide any other details of condition not identified in above assessment. You can also be more specific about some of the brief areas mentioned on this form.

Specifically, what treatments/medications have you already tried, and what results have you seen from these treatments?