Surgery Admission Questionnaire Surgery Admission Questionnaire We need you to take a few minutes of your time to fill out this form as accurately as possible. The questionnaire will help us to better understand our patient and, in turn, help to provide for the best possible anesthetic planning. Client Name * Client Name First First Last Last Pet Name * Email * Cell Phone * Home Phone Work Phone Would you be interested in giving your pet a microchip today? * Yes No Has your pet eaten anything at all during the last 12 hours? * Yes No Has your pet been given any medications, supplements or treatments during the last seven (7) days? * Yes No Please list all that apply * Is your pet a canine (i.e., dog)? * Yes No Has your pet been given Cerenia in the last 12 hours? Yes No Does your pet have any medication or food allergies? * Yes No Please list all that apply * Has your pet had a history of aggressive licking or chewing at surgical incisions? * Yes No Do you anticipate that there will be any problems keeping your pet in a clean, dry area during the recovery process? * Yes No Do you anticipate that there will be any problems keeping your pet reasonably calm during the recovery process? Yes No Do you have any questions for the surgeon this morning? Yes No Please explain * Has your pet ever had a past anesthetic event that you thought went poorly or had a prolonged recovery? Yes No Captcha Submit If you are human, leave this field blank.
