Medical Questionnaire PDF Medical Questionnaire LocationLeesburgRockvilleSpringfieldClient Name(Required) Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Email(Required)Email Phone(Required)PhonePet's Name(Required) Date(Required) MM slash DD slash YYYY Pet Metal Checkbox(Required)Are you aware of any metal in your pet’s body? (i.e. BB’s, plates, pins) Yes No Pet Metal DescriptionIf so, please describe: Pacemaker(Required)Does your pet have a pacemaker? Yes No PregnantIf female, could your pet be pregnant? Yes No Allergies(Required)Does your pet have any allergies that we need to be aware of? Yes No Allergies DescriptionIf your pet has any allergies, please describe: Past Surgeries(Required)Has your pet had any surgeries in the past 3 months? Yes No Past Surgeries DescriptionIf your pet has had any surgeries in the past 3 months, please describe: Past Anesthesia(Required)Has your pet been under anesthesia before? Yes No Past Anesthesia DescriptionIf your pet has been under anesthesia before, please describe: Anesthesia UsedWhat was used (if known)? Past Anesthesia(Required)Did they have any problems recovering from the anesthesia? Yes No Anesthesia ProblemsIf so, please describe: Past Medical ProblemsWhat past medical problems has your pet had? (i.e. heart, lungs. seizures. etc) Special Issues(Required)Does your pet have any special issues we should be aware of? Yes No Blind / DeafBlind / Deaf Yes No Fear of StrangersFear of strangers Yes No Fear of men / womenFear of men / women Yes No Fights RestraintFights Restraint Yes No Needs MuzzledNeeds Muzzled Yes No PhobiasPhobias (loud noises, storms, touching their feet, etc) Yes No Other Special IssuesOther (please list) MedicationsPlease list any medications your pet is currently taking: CAPTCHA
