**[Insert Bennington Animal Hospital Logo Here]**
**Bennington Animal Hospital**
1234 Pet Lane, Bennington, VT 05401
Phone: (555) 123-4567 | Website: www.benningtonanimalhospital.com
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**PUPPY CHECKUP FORM**
**Owner Information**
- **Owner's Name:** ___________________________
- **Phone Number:** ___________________________
- **Email Address:** ___________________________
- **Address:** ________________________________
- **Emergency Contact (Name & Phone):** ___________________________
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**Puppy Information**
- **Puppy's Name:** ___________________________
- **Breed:** ________________________________
- **Age/Date of Birth:** ______________________
- **Color/Markings:** ________________________
- **Gender:** ☐ Male ☐ Female ☐ Spayed ☐ Neutered (if applicable)
- **Weight:** ___________________________ lbs
- **Microchip Number (if applicable):** ___________________
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**Reason for Visit:**
☐ Routine checkup
☐ Vaccination
☐ Illness or injury (please describe) __________________________________________
☐ Behavioral concerns (please describe) ______________________________________
☐ Teething or chewing concerns
☐ Other: ____________________________________
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**Current Medications/Treatments**
(List any medications, supplements, or ongoing treatments)
- ___________________________________________________
- ___________________________________________________
- ___________________________________________________
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**Diet & Nutrition**
- **Primary Food Brand/Type:** ________________________________
- **Feeding Schedule:** ☐ 3-4 meals/day ☐ 2 meals/day ☐ Free feeding ☐ Other:
______________
- **Treats:** ________________________________________________
- **Food allergies or sensitivities (if any):** ________________________________
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**Puppy Care & Development**
- **Current Training (check all that apply):**
☐ Crate training ☐ Housebreaking ☐ Leash training ☐ Socialization with people/other pets
☐ Basic commands (sit, stay, etc.) ☐ Other: ___________________________
- **Teething (check if puppy is experiencing):** ☐ Yes ☐ No
- If yes, describe: _______________________________________________
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**Medical History**
- **Previous Health Issues (check all that apply):**
☐ Allergies ☐ Skin Conditions ☐ Heart Disease ☐ Joint Issues ☐ Respiratory Issues
☐ Digestive Problems ☐ Ear Infections ☐ Urinary Issues ☐ Other (please specify):
_____________________
- **Previous Vaccination History (if applicable):**
- Distemper/Parvo: ___________
- Bordetella: ___________
- Rabies (if old enough): ___________
- Other: ___________
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**Health Concerns (check any current issues or symptoms):**
☐ Lethargy ☐ Vomiting ☐ Diarrhea ☐ Coughing ☐ Sneezing ☐ Itching ☐ Limping ☐ Difficulty
breathing
☐ Changes in appetite ☐ Excessive thirst ☐ Excessive urination ☐ Ear shaking or scratching ☐
Eye discharge
☐ Other: ____________________________________________
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**Physical Exam (Vet Use Only)**
- **Temperature:** ___________°F
- **Heart Rate:** ___________ bpm
- **Respiratory Rate:** ___________ breaths per minute
- **Weight (current):** ___________ lbs
- **Overall Health Assessment (check one):**
☐ Excellent ☐ Good ☐ Fair ☐ Poor
- **Comments/Notes from Vet:**
________________________________________________________
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**Next Steps/Recommendations:**
- ☐ Vaccinations ☐ Deworming ☐ Flea/Tick Prevention ☐ Microchip Placement
- ☐ Socialization Training ☐ Basic Obedience Training ☐ Spay/Neuter (if appropriate)
- ☐ Follow-up Visit: ____________________________
- Additional Recommendations: _________________________________________________
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**Signature of Owner:** ________________________ **Date:** _______________
**Signature of Vet:** __________________________ **Date:** _______________
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