In the veterinary professional curriculum, methods of examination in many courses are transitioning from the traditional paper-based exams to electronic-based exams. Therefore, a controlled trial to evaluate the impact of testing methodology on examination performance in a veterinary physiology course was designed and implemented. Formalized surveys and focus group discussions were also used to determine student attitudes toward the examination formats. In total, 134 first-year veterinary students and 11 PhD/MS students were administered a total of 4 exams throughout 1 semester (2 on paper and 2 electronically) using a split-halves design. The paper (P) and electronic (E) exams contained 25 identical multiple-choice questions. Students were randomly assigned to two groups and were given exams in one of two sequences (E-P-E-P or P-E-P-E). Participants consented to and completed two anonymous surveys vis à vis their experience. Out of a maximum raw score of 25, the mean score for electronic examinations (20.8; 95% confidence interval, 20.3-21.2) was significantly (P = 0.01) greater than that for paper examinations (20.3; 95% confidence interval, 20.0-20.7). However, students expressed numerous concerns with the electronic examination format, and, at the completion of the study, 87% preferred to take their examination on paper rather than the electronic format. These data show that student attitudes concerning the examination format are not primarily determined by examination results, and that the additional anxiety related to the electronic examination format plays a large role in student attitudes.