Table of Contents
What Is a Veterinary Physical Exam Form?
A veterinary physical exam form is a systematic, body-system-by-system checklist used to document every exam — wellness, sick visit, pre-anesthetic, or recheck — so no system gets skipped under time pressure and findings are recorded consistently, visit over visit.
It complements the SOAP note: the objective section of a SOAP note is often built directly from this form's findings. Where the SOAP note tells the clinical story of a visit, the exam form is the structured checklist that makes sure the full physical assessment actually happened.
Working the same order every time is what prevents missed findings. A head-to-tail system order — general appearance, EENT, oral cavity, cardiovascular, respiratory, abdomen, genitourinary, integument, musculoskeletal, neurologic, lymph nodes — turns a rushed exam into a repeatable, defensible process. Two versions are below: a full documentation form and a fast quick-reference checklist.
Required Elements
1Signalment & Vitals
- • Species, breed, sex/reproductive status, age
- • TPR against species-specific typical range
- • Weight and Body Condition Score (/9)
- • Mucous membranes and CRT
2Head-to-Tail Systems
- • EENT, oral cavity/dentition
- • Cardiovascular and respiratory auscultation
- • Abdomen/GI palpation, genitourinary
- • Integument, lymph nodes
3Musculoskeletal & Neuro
- • Gait and lameness assessment by limb
- • Muscle mass and symmetry
- • Mentation and cranial nerve screen
- • Proprioception and reflexes when indicated
4Normal-vs-Abnormal Documentation
- • WNL checkbox per system for fast, complete notes
- • Free-text line for any abnormal finding
- • Problem list tying findings to a plan
- • DVM signature and credentials
Copyable Physical Exam Templates
Use the full form for documentation-grade detail, or the quick-reference checklist when you need a fast pass through every system without slowing down the visit.
Systems-Based Physical Exam Form
Full head-to-tail documentation, any visit type
VITAL SIGNS
T: ___°F (typical dog 99.5–102.5, cat 100.4–102.5)
P: ___bpm (typical dog 60–140, cat 140–220) R: ___brpm (typical dog 10–30, cat 20–30)
Weight: ___ lb/kg BCS: ___ /9 Pain: ___ /4 MM/CRT: ___
SYSTEMS (WNL or abnormal findings)
General/mentation: [ ] BAR [ ] QAR [ ] Dull EENT: [ ] WNL ___
Oral/dentition: [ ] WNL ___ Cardiovascular: [ ] WNL, murmur grade __/6 ___
Respiratory: [ ] WNL ___ Abdomen/GI: [ ] WNL ___
Genitourinary: [ ] WNL ___ Integument: [ ] WNL ___
Musculoskeletal/gait: [ ] WNL ___ Neurologic: [ ] WNL ___
Lymph nodes: [ ] WNL ___
ASSESSMENT / PROBLEM LIST
1. ___________________________ 2. ___________________________
Educational reference only — verify against your practice's medical-record requirements. Not a substitute for professional veterinary judgment.
Quick-Reference Exam Checklist
Fast pass, all systems, minimal writing
TPR: ___°F ___bpm ___brpm Weight: ___ lb/kg BCS: ___ /9
[ ] General appearance / mentation
[ ] Cardiovascular
[ ] EENT
[ ] Respiratory
[ ] Oral cavity / dentition
[ ] Abdomen / GI
[ ] Genitourinary
[ ] Musculoskeletal / gait
[ ] Integument
[ ] Neurologic
[ ] Peripheral lymph nodes
[ ] Mucous membranes / CRT
All systems WNL except: _______________________________________
Educational reference only — not a substitute for professional veterinary judgment.
Visit-Type Variants
The head-to-tail structure holds for every visit type — what changes is which systems get the most attention and how much detail is recorded.
Wellness / Annual Exam
Use the full systems-based form top to bottom — a healthy patient with no complaints is exactly when a complete baseline exam catches early findings like a new murmur or a small mass.
Pre-Anesthetic Exam
Weight cardiovascular and respiratory findings heavily, and pair this form with the anesthesia monitoring sheet's pre-anesthetic checklist (ASA status, fasting confirmation, bloodwork review) before proceeding to sedation.
Focused Recheck Exam
Skip to the specific system being rechecked (e.g., cardiovascular for a murmur recheck) but still record TPR, weight, and BCS every visit — trend data is often more useful than the isolated finding.
Senior Wellness Exam
Add extra detail to musculoskeletal (arthritis screening) and abdominal palpation (organomegaly), and consider a longer visit slot — senior exams commonly surface more findings requiring discussion.
Emergency Triage Exam
Lead with a rapid primary survey (airway, breathing, circulation) before the full systems review, and timestamp every vital sign given how quickly emergency patients can change.
Exam Best Practices
- Work head-to-tail in the same order every time — consistency prevents skipped systems under time pressure.
- Use "WNL" only when you genuinely examined the system and found nothing abnormal — never as a placeholder for a system you skipped.
- Record BCS on a 9-point scale at every visit; it drives accurate weight-based dosing and tracks trend over time.
- Grade abnormal findings with specifics (murmur grade, lameness limb, lesion location/size) rather than vague terms.
- Note reference ranges as "typical" — individual patients vary, especially by breed, age, and stress level in the exam room.
- Sign and credential every exam form; an unsigned or incomplete form weakens the medical record.
Frequently Asked Questions
What body systems should a veterinary physical exam form cover?
A complete systems-based exam covers general appearance/mentation, EENT (eyes, ears, nose, throat), oral cavity/dentition, cardiovascular, respiratory, gastrointestinal/abdomen, genitourinary, integument (skin and coat), musculoskeletal, neurologic, and peripheral lymph nodes — in addition to TPR, weight, and Body Condition Score.
What is Body Condition Score and how is it scored?
Body Condition Score (BCS) is a standardized way to assess whether a patient is underweight, ideal, or overweight, most commonly scored on a 9-point scale (1 = emaciated, 9 = obese) based on palpable ribs, waist, and abdominal tuck. It should be recorded at every visit — it drives accurate weight-based medication dosing and tracks nutritional trend over time.
How long should a full physical exam take?
A thorough systems-based exam commonly takes 10-15 minutes for a routine wellness visit, though this varies by patient temperament, number of findings to investigate, and visit type — a focused recheck exam may take only a few minutes, while a complex or fractious patient may need longer.
What is a normal heart rate and respiratory rate for a dog or cat?
Widely published conventional reference ranges: dogs — pulse 60–140 bpm, respiration 10–30 breaths per minute; cats — pulse 140–220 bpm, respiration 20–30 breaths per minute. These are typical ranges, not absolutes — stress, breed, size, and activity level all cause normal variation.
Should the physical exam form be different for cats versus dogs?
The systems-based structure is the same, but interpret findings against species-specific typical ranges — cats have a faster typical heart rate than dogs, for example — and remember cats often mask pain and illness more subtly, so findings like mild weight loss or slight lethargy carry more weight in a feline exam.
What does "WNL" mean on an exam form, and when should I use it?
"WNL" means "within normal limits" and should only be checked for a system you actually examined and found no abnormality in — using it as a shortcut for a system you didn't fully assess creates a misleading medical record and can be a liability if a missed finding surfaces later.
Can vet techs perform and document parts of the physical exam?
Credentialed veterinary technicians commonly perform and document TPR, weight, BCS, and a general observation as part of a tech appointment or pre-visit workup — but the complete diagnostic physical exam, including auscultation findings and any diagnosis, should be performed and signed off by the supervising DVM.
Is this exam form legally sufficient documentation for my practice?
This template is an educational reference to help structure a thorough, defensible exam record — it is not legal advice. Medical record requirements vary by state veterinary board and by practice policy, so verify your final format against your state's requirements.
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Related Resources
Veterinary SOAP Note Template
Canine wellness and feline sick-visit SOAP templates with writing guide.
Anesthesia Monitoring Sheet Template
Pre-anesthetic checklist plus induction-to-recovery monitoring grid.
Veterinary Treatment Sheet Template
Hospitalization and ICU treatment tracking by time block.
Vet Tech Report Sheet Template
Per-patient tracking card for tech shifts and treatment monitoring.
New Client Form Template
Intake form to pair with a new patient's first physical exam.
Body Condition Score Chart
Free tool: interactive 9-point BCS guide scored during this exam.
Mentation: BAR, QAR & the Full Scale
Grading level of consciousness at the start of the exam.
Capillary Refill Time (CRT) & MM Color
Assessing perfusion via CRT and mucous membrane color.
Dehydration Assessment Guide
Estimating percent dehydration from exam findings.
BCS Chart Explained (1–9 Scale)
The educational companion to the interactive BCS tool.
Pain Scoring in Dogs & Cats
Validated pain scales and how to score a patient on exam.
Heart Murmur Grades (I–VI)
Grading murmurs heard on cardiac auscultation.
Fecal Scoring Chart (1–7)
Scoring stool consistency documented with GI findings.