Dog Health Screening: Veterinarian Assessment Form

Delta Therapy Dogs is a national not-for-profit organisation which promotes the social, physical and emotional benefits of positive interaction between people and therapy animals.

As part of our programs, Therapy Dog Teams - which are made up of volunteers and their pet dogs - visit sick children and adults in hospitals, elderly residents in aged care facilities, inmates in prisons, and any other health or community service where Animal Assisted Interventions can enhance quality of life.

Your client is either a current Therapy Dog Team volunteer and is undergoing re-assessment, or has applied to our organisation to take on the role.

Delta Therapy Dogs have a strong focus on the welfare of our Therapy Dogs, and so it is important to us that the dogs are not adversely impacted during their participation in the program.

We appreciate therefore that you take your time in conducting the following examination and completing this assessment form accurately and frankly. Though I am sure your client will want to know your recommendation in relation to the dog's suitability to participate in the program, we have created this online form so that all detailed comments come directly to Delta so as to encourage your complete honesty.

If you have any issues you can contact the Delta Therapy Dogs Programs Coordinator for your state: https://www.deltasociety.com.au/about-us

Otherwise thank you in advance for you professional opinion.

Veterinarian's Details:

Vet's Name:*

First NameLast Name

Vet's Registration No.*

As per your State's Registration Board

Vet's Practice Name:*

Vet's Practice Address:*

Street Address

Street Address Line 2

Suburb / CityState

Post Code

Vet's Practice Phone No.*

Area CodePhone Number

Vet's Practice Email:*

example@example.com

Guardian/ Dog's Basic Details:

Client's Name:*

First NameLast Name

Client's Email:*

example@example.com

State in which your client resides:*

Dog's Name:*

Dog's Breed:*

Dog's Age:*

In years and months

Is the dog:*

NeuteredEntire

How often do you see this dog?*

Regular wellness programOnly when ill / required

Dog's Vaccination and Parasite Program Details:

Please confirm the current status of the dog's vaccinations, noting C5 is required by Delta Therapy Dogs: *

	Date of last Vaccination:
Canine Distemper
Canine Parvovirus
Infectious Canine Hepatitis
Canine Cough (Bordetella bronchiseptica and adenovirus Type 2)

Please up-load a copy of the dogs immunisation certificate (either full C5 or Canine Cough only if supplying a Titre Test Certificate in replacement of distemper, parvovirus and hepatitis vaccinations):*

Browse Files

If relevant please up-load a copy of the Titre Test Certificate confirming immunity to distemper, parvovirus and hepatitis as tested within the last 12 months. Please note Canine Cough Vaccination Certificate is still required.

Browse Files

In your opinion is the dog on an effective program for the control of the following:*

	Effective
Heartworm
Intestinal parasites
External parasites

Dog's General Health:

As part of the dog's participation in the program they are undertaking visits of up to 90minutes in duration. In this time they are moving throughout a facility and interacting with many staff and program beneficiaries.

Depending on the type of facility the dog may be required to stand for periods next to a chair, bed or person for pats; climb or be lifted on to someone's lap or bed; and may even need to undertake physical activities such a jumping and catching balls if participating in a rehabilitation program.

Please keep these activities in mind when assessing the dog's health and suitability to participate in the program, and note whether there are any limitations.

Does the dog have any pre-existing condition/s which could impact on their successful participation in the program:*

YesNo

If you answered yes to the above, please provide more information:

Please note whether during observation the dog was normal or impaired in the following:*

	Normal	Impaired
Locomotion (gait, lameness, paresis)
Hearing (relative to age)
Sight (relative to age)

If you marked the dog as impaired in one of the areas above, please provide further comment:

Do you believe the dog's weight is within normal range for its breed:*

YesNo

If you answered no, do you believe that the dog will suffer adversely by participating in the program if it is not within its normal weight range:

YesNo

If you answered no, do you believe that the dog will suffer adversely by participating in the program if it is not within its normal weight range:

Overall, would you say that the general health of the dog is:*

Excellent - no chronic disease or disorderVery Good - minor complaints associated with normal agingGood - chronic conditions resulting in occasional flare-upsPoor - chronic illness requiring on-going treatment

Dog's Reactions to Examination:

Please evaluate the dog's reaction to being handled and examined.

Mark the column 'Accepts Handling' if the dog remains calm or the 'Dislikes Handling' column if the dog becomes aggressive, resentful or excessively fearful. *

	Accepts Handling	Dislikes Handling
Eyes (lids, conjunctiva, cornea)
Ears (appearance, discharge, mites, odour)
Nose (appearance, pad, discharge)
Mouth/Throat (breath, teeth, gingival)
Head and Neck (manipulation)
Withers and Back (deformities, swelling, tenderness)
Thorax (shape, auscultation)
Abdomen (tension, tenderness, sensitivity to palpation)
Mammary glands & genitalia (sensitivity to palpation)
Legs & Feet (tenderness, joint movement, sensitivity to manipulation)
Palpation between pads & toenail trimming)
Skin (colour, odour, haircoat)
Tail (anal sacs, sensitivity to manipulation)

Please provide further comment on specific reactions to examination if 'Dislikes Handling' was marked for any category:

Please provide comment on any physical problems that were identified during examination which may put the dog at risk:

Health Assessment Outcome:

In order for the dog to enter or remain as part of the Delta Therapy Dogs Program they need to:

Be up-to-date with their C5 vaccinations;
Have an effective parasite prevention program in place;
Be healthy, with no indication that their health would impinge on their ability to work as a Therapy Dog;
Accept handling during examination; and
Not be adversely affected by participating in the program.

Given this criteria would you assess the dog as being:*

SuitableNot suitable right now (but could be once their health improved)Not suitable

Please feel free to provide further comment or explanation for your assessment:

Examination Date:*

Date

Vet's Signature:*

Privacy Policy