About this template
This veterinary EMR and SOAP exam template is designed to help veterinary practices record comprehensive physical examinations and treatment plans digitally. Based on the standard SOAP (Subjective, Objective, Assessment, Plan) format, this form captures vital client contact details alongside detailed patient metrics including temperature, pulse, respiration, body condition score, and system-by-system physical findings.
Built for busy veterinary clinics, animal hospitals, and mobile vets, this template eliminates messy paper records by organizing patient histories and diagnostic notes directly into a spreadsheet. Whether you are conducting routine wellness checks or emergency evaluations, this form standardizes your documentation process, ensuring clear communication between veterinarians, veterinary technicians, and pet owners.
Key features
- Standardized SOAP format for consistent physical exams
- System-by-system health check tracking (eyes, ears, heart, lungs, etc.)
- Vital signs and body condition score recording
- Diagnostic notes and treatment plan documentation
- Client and patient detail organization in one secure sheet
Use cases
- Routine annual checkups and wellness examinations
- Emergency veterinary intake and triage
- Specialist consultations and follow-up visits
- Mobile veterinary practice record keeping
What this form collects
- Appointment Date and Time (Date)Select the date and time of the current visit.
- Client Full Name (Short answer)Enter the first and last name of the pet owner.
- Client Phone Number (Short answer)Primary contact number for the owner.
- Client Email Address (Short answer)Where visit summaries and invoices will be sent.
- Client Address (Paragraph)Street address, city, and zip code.
- Patient Name (Short answer)Name of the pet being examined.
- Patient Birthdate or Age (Short answer)Estimated or known birth date.
- Patient Sex / Spay-Neuter Status (Multiple choice)Select the appropriate status.
- Species (Multiple choice)Select the animal species.
- Breed (Short answer)Specify the breed or mix.
- Weight (Short answer)Enter the numeric weight measurement.
- Weight Unit (Multiple choice)Select lbs or kg.
- Presenting Complaint (Dropdown)Primary reason for today's visit.
- Subjective History (Paragraph)Client observations regarding appetite, behavior, and duration of symptoms.
- Vitals: Temperature (°F) (Short answer)Recorded body temperature.
- Vitals: Pulse / Heart Rate (bpm) (Short answer)Heart beats per minute.
- Vitals: Respiration (bpm) (Short answer)Breaths per minute.
- Body Condition Score (BCS) (Dropdown)Select the score based on standard 1-9 or 1-5 scale.
- Physical Exam: Oral Cavity & Teeth (Paragraph)Note status and any abnormalities (e.g., tartar, gingivitis, broken teeth).
- Physical Exam: Eyes (Paragraph)Note discharge, clarity, sclera, and vision check.
- Physical Exam: Ears (Paragraph)Note discharge, odor, erythema, or pain on palpation.
- Physical Exam: Cardiovascular (Heart) (Paragraph)Note murmur, arrhythmia, or normal auscultation.
- Physical Exam: Respiratory (Lungs) (Paragraph)Note crackles, wheezes, increased effort, or clear sounds.
- Physical Exam: Abdomen (Paragraph)Note palpation findings (soft, tense, painful, organomegaly).
- Physical Exam: Musculoskeletal & Neurological (Paragraph)Note lameness, gait, reflexes, and joint stability.
- Diagnostics Performed (Checkboxes)Select tests performed during the visit.
- Diagnostic & Lab File Links (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
- Assessment / Diagnosis (Paragraph)Veterinarian's assessment and clinical diagnosis.
- Treatment Plan and Recommendations (Paragraph)Prescriptions, home care instructions, follow-up timeline, and next steps.
- Attending Veterinarian (Short answer)Name of the examining vet.
FAQ
How can I customize this veterinary form for my clinic?
With Doc2Form, you can instantly turn this template into a fully editable Google Form, allowing you to add clinic-specific fields, logo imagery, or modified physical assessment categories.
Where are the examination submissions stored?
All responses are automatically routed to a connected Google Sheet, giving your veterinary team an instant, searchable database of patient records.
Can veterinary technicians fill out this form during exams?
Yes! The form is fully responsive on tablets and mobile devices, making it easy for staff to record vitals and observations chairside.
How do I attach lab work or X-rays to the patient record?
While Google Forms does not support direct file uploads from respondents, you can use the designated file link field to paste URLs from cloud storage services like Google Drive or Dropbox.
Is this template free to use?
Yes, this template is completely free to copy and adapt for your veterinary practice using Doc2Form.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.