Surgery Service Pre-Surgical Questionnaire Surgery Service Pre-Surgical Questionnaire 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 Information Pet Name * Has your pet had any major illnesses or injuries in the past (ie. hit by a car, GI disease?) Does your pet have any chronic conditions (ie. arthritis, thyroid disease, diabetes, allergies, seizures)? Briefly, why is your pet here today? * Has your pet had any anesthetic procedures in the past (dental cleaning, surgery)? How did your pet recover from that procedure? When did these symptoms begin? * Please list any medications your pet is currently taking or has taken in the past week, including preventives, etc. Does your pet take any supplements such as joint supplements, fish oils, etc.? Have these symptoms * ImprovedWorsenShown no change Does your pet have any known drug allergies or sensitivities? How do you administer your pet's medications (in food, with treats, etc.)? 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 Describe your pet's interactions with other pets and people (fearful, friendly, etc.) Is your pet known to have any degree of separation anxiety or fears? If so, please describe. Have you noticed any changes in your pet's behavior (ie. reluctance to do things, aggression, changes in urination or bowel habits)? Please describe your pet's environment (check all that apply) Stairs to manuever Allowed on furniture Other pets Fenced yard Smooth floors Crate trained Pee-pad trained What do you feed your pet (brand, wet/dry, frequency, amount) Describe your pet's normal eating habits Does your pet have any dietary restrictions, sensitivities, or allergies? Is there anything else you wish to share with us today? Submit If you are human, leave this field blank.
