Surgery Questionnaire

Full Name *

Primary Phone Number *

Email Address *

Do you have medical insurance for your pet? *

Yes
No

Do you consent to your pet being featured in educational or promotional materials (e.g., websites, social media, or presentations)? This may include photos, diagnostic images, medical information, and your pet's first name. *

Yes
No

In just a few words please indicate the problem you are coming in for *

What signs did you first notice? *

How long have the signs been going on for? *

Has the problem progressed/not changed/improved? *

What medications is your pet currently taking?

include any medications including those for other conditions, along with supplements or over the counter medication

Does your pet pay attention to the problem? *

eg. Turning suddenly, scratching, chewing, licking

Yes
No

Indicate 0 if normal/not affected and 5 if profoundly affected/unable to perform.

When are signs most pronounced? *

First thing in the morning or when getting up from laying down
At the start of exercise but then "warms out of it"
At some point during or near the end of exercise
Always

OTHER HEALTH CONCERNS OR COMMENTS

Are there other health or behavioural concerns that impacts your pet? *

Are there any other concerns we should be aware of? *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

The ability to rest comfortably	0 1 2 3 4 5 N/A
Walking	0 1 2 3 4 5 N/A
Trotting/running	0 1 2 3 4 5 N/A
Jumping up	0 1 2 3 4 5 N/A
Jumping down	0 1 2 3 4 5 N/A
Appetite	0 1 2 3 4 5 N/A
Ability to do normal daily activities in comfort	0 1 2 3 4 5 N/A
Overall energy levels	0 1 2 3 4 5 N/A
Interest in daily activities and interaction with you	0 1 2 3 4 5 N/A
Interaction with other pets	0 1 2 3 4 5 N/A

Surgery Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

PRESENTING PROBLEM

MEDICATIONS

QUALITY OF LIFE

OTHER HEALTH CONCERNS OR COMMENTS

Surgery Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

PRESENTING PROBLEM

MEDICATIONS

QUALITY OF LIFE

OTHER HEALTH CONCERNS OR COMMENTS

Our Cookies

About Cookies

Cookie settings

Functional cookies

Analytics cookies

Marketing cookies