Owner's Name(Required) Patient Name(Required) The questions below are extremely important to answer as correctly as possible. There is always a risk with anesthesia and surgery. Sometimes unforeseen complications do arise. We want your pet to have a good post- operative recovery without any secondary problems. To minimize the risk of complications, we start with a good history and physical exam. Please check yes or no for each question:Is your pet drinking water excessively?(Required) Yes No Is your pet eating normally?(Required) Yes No ls your pet sleeping more than usual?(Required) Yes No ls your pet coughing, hacking or sneezing?(Required) Yes No Does your pet have any gastrointestinal problems like vomiting, diarrhea or excessive gas in the last 2 weeks?(Required) Yes No Have you noticed any skin problems in the last 2 weeks?(Required) Yes No Have you seen any fleas or ticks in the last 4 weeks?(Required) Yes No Have you seen any patches of bruising on the skin in the last 4 weeks?(Required) Yes No Do you use rat poison?(Required) Yes No ls your pet up to date on vaccines?(Required) Yes No Date of last vaccines(Required) MM slash DD slash YYYY Where?(Required) ls your pet on any medication or supplements? (prescription or over the counter)(Required) Yes No Does your pet have any hereditary problems?(Required) Yes No If yes, what is it?(Required) ls your pet currently on heartworm prevention?(Required) Yes No Have you noticed any episodes of lethargy, exercise intolerance, being tired or fainting?(Required) Yes No ls your pet a brand new addition to the family?(Required) Yes No Does your pet have any allergies?(Required) Yes No lf you have any other information that can be beneficial, please make a note.Signature(Required)Date(Required) MM slash DD slash YYYY