Pre-Anesthetic/Sedation Questionnaire Your pet is here for a procedure that requires general anesthesia or sedation. Please take a moment to complete these questions so we may provide the best care possible for you and your pet.Today's Date* MM slash DD slash YYYY Owner's Name* First Last Pet's Name* What time did your pet last eat?*What time did your pet last drink?*Has your pet had any of the following problems in the past week?* Vomiting Diarrhea Coughing Sneezing Skin Rash Change In Appetite None Does your pet have any major medical issues? (Seizures, Diabetes, Heart Problems)*Select OneYesNoIf the previous answer is yes, please explain:Does your pet have any food allergies or restrictions?*Select OneYesNoIf the previous answer is yes, please explain:Is your pet allergic to any medications?*Select OneYesNoIf the previous answer is yes, please explain:Please list your pet's medications (including supplements/vitamins):Size(mg) - #Pills Per Dose - #Times Per Day - Date Last Given - Time Last Given Has your pet taken any Aspirin within the last month?*Select OneYesNoMy pet is here for:*Is your pet limping?*Select OneYesNoWhich leg is your pet limping on? Left Front Right Front Left Rear Right Rear None of the Above
