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WAIDIN  MI-KI
VETERINARIAN CHECKLIST

REGISTERED NAME OF MI-KI:_______________________DATE OF BIRTH:____________________
REGISTRATION #:__________________________________MICRO CHIP#: _____________________
COLOR/DESCRIPTION:_________________________________________________________________
DATE OF EXAMINATION: _______________ AGE OF EXAMINATION: ________________

Hearing: _____ Normal _____ Abnormal (describe) ___________________________

Dental: _____ Overshot _____Scissor Bite _____ Level Bite _____Undershot
_____ Other (Please describe) _____________________________________

Fontanel Opening: ____Absent ____Present (size of opening)________________

Genitourinary:
A. Male: Testicles ____Present ____Absent: ___One ___Both (not descended)
B. Female: Any genitalia abnormalities ____Absent ____ Present (describe)__________
________________________________________________________________________

Hernias:
A. Umbilical: ____Absent ____Present (size mm) _____________________________
B. Inguinal: ____Absent ____Present (location/size) ___________________________

Evidence of Medical or Cosmetic Surgery:
___Absent ____ Present (describe) ________________________________________
Indication of infection or disease: ____Absent _____ Present (describe) ___________
________________________________________________________________________

Ophthalmic: (CERF exam attached)
Eyes: _____Normal _____Abnormal (describe) _______________________________
________________________________________________________________________
Iris Color: _____ Brown _____Blue _____other: ___________________________

Cardiovascular: (Cardiologist exam attached)
Abnormalities: _____Absent _____ Present (describe) ________________________
________________________________________________________________________

Orthopedic: (OFA Patella Luxation form attached)
Legs: _____Normal (all feet touching the ground flat) _____ Abnormal (describe)___
________________________________________________________________________
Leg-Perthes: _____Absent _____ Present (describe) __________________________
________________________________________________________________________
Foot/toe abnormalities: _____Absent _____ Present (describe) ________________
________________________________________________________________________

Additional comments: _____________________________________________________
_______________________________________________________________________

VETERINARIAN: Daryl L. Waits, Jr,. DVM
Fayette Veterinary Hospital, 1974 Columbus Ave., Washington Court House, Ohio 43160
PHONE: 740-335-6161
VETERINARIAN'S SIGNATURE: ________________________________________________