SAMPLE FORMS – FOOD PRODUCING ANIMALS

The attached documents are intended as samples which provide a veterinarian with forms that he/she may choose to consider or adapt as part of their food producing animal practice. In addition to forms that apply to food producing practice, documents with forms specific to equine, poultry and companion animals are available as well as forms that may be used by all practices.

Sample Form Page

Client / Herd Identification Sheet (Bovine) 2

Food Producing Animal Client Information Sheet 3

Food Producing Animal Medical Record 4-5

Food Producing Animal Continuing Care Summary Sheet 6

Herd Health Master Problem List (Bovine) 7

Herd Health Reproduction Record 8

Herd Health Vaccination Record 9

SAMPLE: CLIENT/HERD IDENTIFICATION SHEET (BOVINE) Client ID #

Herd ID #

Client Information

Client Name

Civic Address

Farm Name/Address

Phone Home: Work: Cell: FAX:

Email

Alternative Contact Information

Name Phone Cell Position Decision Maker

Yes/No

Other Herd Veterinarians Name Phone Cell Position/Company

Herd Information Artificial Insemination

Bull

Free Stall

Tie Stall

Production Type: Dairy

Cattle Sales

Breed ______________

Purebred / Grade

Leukosis control program

YES / NO

DHI REG

YES / NO

Johnes control program

YES / NO

Johnes neg

YES / NO

Current Johnes

YES / NO

Herd Health Day Herd Health Day: Weekly Bi-Weekly Monthly Owner to book Time:

Herd Health Summary:

Vaccination Hx Inforce 3 Protocol Yes/No Code: Clostridial Protocol Yes/No Code:

Lepto Protocol Yes/No Code: Enviracor Protocol Yes/No Code:

Scour Protocol Yes/No Code: 1st Defence Protocol Yes/No Code:

BVD/IR Killed / Modified Protocol Yes/No Code:

Parasite Control Pour On: _________________ Yes / No Annual / Bi-Annual Protocol Yes/No Code: Other insecticides: Ear tags ______________ Yes / No Topical: ___________________ Yes / No

Foot Bath Yes / No

Veterinary Product: Yes / No Protocol Yes/No Code:

Veterinary Product: Yes / No Protocol Yes/No Code:

SAMPLE: FOOD PRODUCING ANIMAL CLIENT INFORMATION Client ID #

Animal ID #

Client is owner or Client is authorized representative of owner

Multiple owners1

CLIENT INFORMATION:

Name:

Address 1:

Address 2: (lot, concession, township, stable/barn)

Phone: Home: Work: Cell: FAX:

Email Permission and Address:

Permission to transmit confidential information via email: Yes No

Address:

EMERGENCY CONTACT:

Name:

Address:

Phone: Home: Work: Cell: FAX:

Email:

Consent to act as client’s agent: Yes No

Authority for decision making: Financial: Up to $_______________

Medical Care:

Signature Client: Date:

Signature Veterinarian: Date:

1 Attach additional sheets as necessary for contact information of multiple owners.

SAMPLE: FOOD PRODUCING ANIMAL MEDICAL RECORD

Client ID: Animal/Herd ID:

Veterinarian: Date:

History / Previous Treatment Has another veterinarian been consulted? Yes Dr. __________________________ No

Presenting Complaint

Physical Examination

T: (F/C) HR: bpm RR: min

Weight / Body Condition:

Attitude: BCS:

Reproductive Status: Pregnant / Open / Fresh / Bred / Immature

Appetite: Normal / Partial / Absent Duration:

Signification Findings:

Client ID #

Animal ID #

Assessment:

Specimens Taken:

Instructions to Client: Product Amount Route Frequency Duration

Treatment Plan

Withdrawal Instructions (if applicable) Milk withdrawal: __________hours Meat withdrawal: _________ hours

Milk from this animal, taken at the am / pm milking, may go into the tank on DD/MM/YYYY if administered as prescribed.

Milk from this animal must be subject to Inhibitor Testing before the milk may go into the tank.

The recommended date for Inhibitor Testing is the am / pm of DD/MM/YYYY.

This animal may be shipped for slaughter on DD/MM/YYYY

________________________________________ Veterinarian Signature

____ / ____ / ____ Date:

SAMPLE: FOOD PRODUCING ANIMAL CONTINUING CARE SUMMARY

Client ID: Animal ID:

Diagnosis:

Treatment / Tests:

Medications:

Withdrawal Times:

Dietary Directions:

Recheck Date:

Additional Instructions:

Veterinarian Signature: Date:

SAMPLE: HERD HEALTH MASTER PROBLEM LIST (BOVINE)

Year

Client ID #

Herd ID #

Herd Problem Codes: Pneumonia, Mastitis, LDA, Ketosis, Retained Placenta, Deaths, Indigestion, Reproductive

Date Code Diagnosis Group

Affected Treatment Comment Init.

SAMPLE: HERD HEALTH REPRODUCTION RECORD

Year

Client ID #

Herd ID #

Veterinarian: Date:

Date Herd ID # Services Date

Conceived Date Fresh

# Days Open

Remarks Initials

Total # of Services: Total # of Days Open:

Avg. # of Services / Conception: Avg. # of Days Open:

First Service Conception Rate:

SAMPLE: HERD HEALTH VACCINATION RECORD (where no protocol exists)

Client ID: Animal/Herd ID:

Veterinarian: Date:

Disease to be vaccinated for: IBR, BVD, PI-3, BRSV / Leptospirosis

Age group to be vaccinated:

Vaccine Type:

Primary Dose:

Site of Administration:

Dosage and needle size:

Slaughter or milk withdrawal:

Disease to be vaccinated for: Neonatal Scours

Age group to be vaccinated:

Vaccine Type:

Primary Dose:

Site of Administration:

Dosage and needle size:

Slaughter or milk withdrawal:

Disease to be vaccinated for:

Age group to be vaccinated:

Vaccine Type:

Primary Dose:

Site of Administration:

Dosage and needle size:

Slaughter or milk withdrawal: