Surgical Admission Questionnaire

Client Information

Name*

Address*

Street Address City State ZIP Code

Primary Phone Number*

Type*

Cell
Home
Work

Secondary Phone Number

Type

Cell
Home
Work

Email Address*

Pet Information

Name*

Breed*

Canine
Feline
Other

Age*

Gender*

Male
Female

Spayed/Neutered*

Yes
No

Please Fill Out Completely

Today's date:*

Surgery/Procedure your pet is receiving today*

When did your pet last eat?*

Does your pet have food allergies or require a special diet?*

Yes
No

If Yes, please explain

Has your pet had any vomiting or diarrhea in the last 48 hours?*

Yes
No

If Yes, please explain

Does your pet have any history of drug sensitivities?*

Yes
No

If Yes, please explain

Does your pet have any history of thyroid disease?*

Yes
No

If Yes, please explain

Does your pet have any history of Cushing’s disease?*

Yes
No

If Yes, please explain

Does your pet have any history of diabetes?*

Yes
No

If Yes, please explain

Does your pet have any history of kidney disease?*

Yes
No

If Yes, please explain

Does your pet have any history of seizures?*

Yes
No

If Yes, please explain (Last one? How often?)

Does your pet have any history of heart disease?*

Yes
No

If Yes, please explain

Does your pet have any history of respiratory disease?*

Yes
No

If Yes, please explain

Does your pet have any history of liver disease?*

Yes
No

If Yes, please explain

Please enter any other medical issues or history not listed above.

Please list all medications given in the last week:

Drug	Dose (mg)	Frequency	Reason	Time Last Given	Quantity Remaining

Does your pet need sedatives/anti-anxiety meds to be crated/confined AT HOME after surgery?*

Yes
No
Maybe

Additional Notes

Has your pet had any adverse anesthetic events?*

Yes
No

Additional details:

Has your pet had recent blood work?*

Yes
No

When? Where?

Does your dog need special commands or surfaces for elimination outside (e.g. “Go potty”, “Hurry up”, grass only, wee wee pads)?*

Yes
No

If Yes, please explain

Has your pet ever received a blood transfusion or carried a litter?*

Yes
No

If Yes, please explain

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