What to include in a pet health record (checklist)

What belongs in the record

AAHA’s storm preparedness page says to keep copies of vaccination records, medication instructions, medical conditions, and the vet’s contact information together, and to replace outdated records.¹ VCA Animal Hospitals adds drug and food allergies, vaccine reactions, weight trends, and handling preferences to what a new vet needs to see.⁴

For cats, AAHA’s feline life-stage guidelines say a new patient needs prior medical or surgical information, including past or current medication and supplements.² They also say to record diet and body weight so a change can be seen over time, and that photos can help track body condition. A weight without a date cannot be compared with the next one.

Fields worth keeping current

What to include	Why it is there
Name, species, and a recent photo	So the next clinic can match the record to the pet.
Microchip number	AAHA suggests asking the vet to scan the chip and check the number is in the record.³ The Canadian Veterinary Medical Association recommends a scan every year.⁶
Clinic contacts	So the next person knows who to call.
Vaccinations	Each vaccine, the date given, and the date due, from the clinic’s certificate.
Allergies and reactions	The medication, food, or vaccine, what happened, and when.
Medication and supplements	Copied from the current label. The full list is its own page.
Weights with dates	So the next weight can be compared with this one.
Usual routine	Diet, activity, and bathroom habits, so a change stands out.
Handling notes	What helps at the clinic, such as a covered carrier.
Recent change	What you noticed, the date, and whether you or the clinic is the source.

Source and date

“Owner saw this on July 18” and “copied from discharge instructions dated July 12” are different kinds of fact. Write which one it is. A line without a source gets treated as stronger than it is, or discarded.

Cornell’s hospital says the clinic’s record is how you and your vet stay informed of the treatment, and that you can ask for a copy.⁵ In Ontario, the College of Veterinarians of Ontario says a clinic must give you a copy when you ask.⁷ Keep that file, or ask for it, instead of rewriting a result from memory. For a one-page version to hand a new vet, use the pet medical history template.

When to update it

Update the record after a visit, when instructions change, and before travel or a new clinic. A short current record is more useful than a large archive no one can scan. Sending it is covered in Share or transfer pet records to a vet.

Sources

Storm Preparedness for Pets: Shelter and Evacuation Planning, American Animal Hospital Association
Medical History and Physical Examination Focus Based on Specific Life Stage, American Animal Hospital Association
10 Things You Need To Know About The AAHA/AVMA Preventive Healthcare Guidelines, American Animal Hospital Association
The Importance of Sharing Medical Records, VCA Animal Hospitals
Admissions, Discharge, and Medical Records, Cornell University College of Veterinary Medicine
Microchip Animal Identification in Small (Companion) Animals, Canadian Veterinary Medical Association
Guide to the Professional Practice Standard: Medical Records, College of Veterinarians of Ontario

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