Surgery Service Pre-Surgical Questionnaire Surgery Service Pre-Surgical Questionnaire - Updated 9.3.2025 Client's Name * Client's Name First First Last Last Email * Phone (cell) * What is the best number to contact the person making the medical decisions for the pet? Pet Name * What is your primary concern with your pet today? * When did the symptoms begin? * Have these symptoms * Improved No change Worsened Have you observed any of the following conditions in your pet (choose all that apply) Vomiting Diarrhea Weight loss Weight gain Decreased appetite Increased appetite Increased thirst Increased urination Coughing Sneezing Exercise intolerance Trouble breathing Has your pet had any major illnesses or injuries in the past (i.e. hit by a car, GI disease?) * Yes No If yes, please describe illness or injury * Does your pet have any chronic conditions (i.e. arthritis, thyroid disease, diabetes, allergies, seizures)? * Yes No If yes, please describe chronic condition(s) * Has your pet had any complications from anesthesia or sedation in the past? * Yes No If yes, please explain complication * List any medications (prescribed, over the counter, supplements, preventatives) your pet is currently taking or has taken in the last week: Does your pet have any allergies/ reactions to medications or food? * Yes No If yes, please list allergies/ reactions to medications or food * What Diagnostics has your pet had in the last 6 weeks? (check all that apply) Blood Work Heartworm Testing X-rays Ultrasound Fine needle Aspirate OtherOther Any specific questions or concerns? Submit If you are human, leave this field blank.
