NATIONAL UNIVERSITY OF SAN MARTIN

FACULTY OF AGRICULTURAL SCIENCES

Professional Academic School of Veterinary Medicine
Veterinary Gynecology and Obstetrics
CLINICAL HISTORY N°………….
I. GENERAL DATA:
Name of the Estate:......................................................................................................
Location :.......................................................................................................................
Owner :..........................................................................................................................
Production Type:...........................................................................................................
Date :.............................................................................................................................

II. PATIENT REVIEW:

Species:……………………………………. Race:…..…………………………………..
Sex:………………………………….. Age:………………………………………
Color :…………………………………. Body Condition:…………………………
Earring number:............................................................................................................
Reproductive Status: Empty ( ) Pregnant ( ) Newly calved ( )
Observations:................................................................................................................
......................................................................................................................................
......................................................................................................................................

III. ANAMNESIS
III.1............................................................................................................What type of food do you eat?:
Grazing ( ) Concentrated ( ) Corn/Sorghum ( ) Grazing/Concentrated ( )
Food consumption: Normal ( ) Decreased ( ) Does not eat ( )
Observations:................................................................................................................
......................................................................................................................................
III.2...............................................................................Behavior: Normal ( ) Aggressive ( ) Restless ( ) Shows d
Is the animal standing or prostrate?.............................................. ....................
If you are standing, how do you walk?: Reluctant ( ) Hesitant ( ) Reluctant ( )
III.3...............................................................................Skin and coat: Normal ( ) Hirsute ( ) Lumps/Swellings (
III.4. Functional Alterations: Temperature:…………….°C Pulse:…………/min.
Respiratory Rate:…………/min. Rhythm?..................Type?.....................
Heart Rate:………./min. Rhythm?.................Type?............................... ...........

Gynecology is not a specialty of medicine, but rather a paraphilia of life.

 NATIONAL UNIVERSITY OF SAN MARTIN
FACULTY OF AGRICULTURAL SCIENCES
Professional Academic School of Veterinary Medicine
Veterinary Gynecology and Obstetrics
Ruminal Movements:……………../2min Is there atony? But ( )
Is the animal tympanic? But ( )
Observations:..............................................................................................................
....................................................................................................................................
III.5. Mucous membranes:

Normal Jaundiced Hyperemi Cyanotic Pale

MUCOUS
(Rosacea) (Yellow) a (Red) (Red) (White)
Ocular
Oral
Nasal
Rectal
Vulvar

Observations:..............................................................................................................
....................................................................................................................................

IV. HEALTH SHEET

Patient No.
Vaccine Date Observations
or Name

Gynecology is not a specialty of medicine, but rather a paraphilia of life.

 NATIONAL UNIVERSITY OF SAN MARTIN
FACULTY OF AGRICULTURAL SCIENCES
Professional Academic School of Veterinary Medicine
Veterinary Gynecology and Obstetrics
VII. MILK PRODUCTION SHEET

Calf Domestic
Cow Calf Plant Total Average
Date colostru Consump
No. milk Sale production Milk/Cow/Day
m tion

Gynecology is not a specialty of medicine, but rather a paraphilia of life.

 NATIONAL UNIVERSITY OF SAN MARTIN
FACULTY OF AGRICULTURAL SCIENCES
Professional Academic School of Veterinary Medicine
Veterinary Gynecology and Obstetrics

Gynecology is not a specialty of medicine, but rather a paraphilia of life.