PRE-ANESTHESIA EVALUATION - Virtual Check-In
The following health history/risk assessment communicates valuable information to your pet's surgical team. It should take about 5-10 minutes to thoughtfully complete this form, and is best completed by your pet's primary caregiver.
Pet's Primary Adult Caregiver - Full Name
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First Name
Last Name
Pet's Other Adult Caregiver(s) if Any
Name(s)
Valid Caregiver E-mail
Preferred Phone Number Confirmation
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Area Code
Phone Number
When Patient is In Recovery How Would You Like to Be Contacted?
Text
Phone Call
Other
Pet Patient's Name
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Date of Scheduled Procedure
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Month
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Day
Year
Date
If different than the caregiver(s) listed above, who is the adult person presenting this pet patient to Highland during the appointment/check in time?
First Name
Last Name
Goals for today's procedure
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List your understanding of the purpose of this anesthetic procedure or visit, and/or any questions you have about the procedure.
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Next - General Information
GENERAL INFORMATION
Patient Species
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Canine (Dog)
Feline (Cat)
Are your dog's vaccine's current to your knowledge?
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All of my dog's vaccines are current as given by Highland Veterinary Clinic
My puppy has some boosters due
My adult dog has some vaccines which have lapsed
I do not know, I understand if Bordetella Bronchispectica, the Distemper/Parvovirus Series, or a Rabies vaccine is due, then these vaccines must be administered, and I may request the cost of these vaccines.
Are your cat's vaccine's current to your knowledge?
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All of my cat's vaccines are current as given by Highland Veterinary Clinic
My kitten has some boosters due
My adult cat has some vaccines which have lapsed
I do not know, I understand if my cat's Paneleukopenia/Upper Respiratory Vaccine, or a Rabies vaccine is due, then these vaccines must be administered, and I may request the cost of these vaccines.
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Next - Pre-Procedure Planning
Pre-Procedure Planning
Medication I
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My pet is currently taking, or is routinely prescribed prescription medication other than routine prevention (i.e. vaccines, heartworm/flea/tick prevention)
My pet is not taking nor are they prescribed any medications other than routine prevention (i.e. vaccines, or heartworm/flea/tick prevention)
Medication II
Please list all routinely prescribed medication other than routine prevention and please state the most recent successful dose or in clinic administration (date and or time). Please describe your pet’s medication regimen and if we can expect your patient has received a medication prior to admission please indicate the time.
Medication III
I will need refills of this medication today, or soon
I need help with compliance--this medication is difficult to give or fit in with our routine
I would like this medication sent to our door via your online pharmacy
Heartworm Test Status
My dog tested negative for Heartworms LESS Than 180 Days Ago
My dog tested negative for Heartworms, MORE than 180 Days, but LESS than 365 days ago
My dog has not had a Heartworm Test within the last year AND they are older than 6 months of age--PLEASE PERFORM THIS TEST.
My dog has not had a Heartworm Test within the last year AND they are older than 6 months of age--I WOULD LIKE TO DECLINE THIS TEST.
My Dog is a Heartworm Positive Patient and is not Yet in Treatment Under a Veterinarian
Feline Retrovirus (FLV/FIV) and Heartworm Test Status
My cat tested negative for FIV and FLV 181-365 days ago and has not been exposed to new cats, nor do they roam outside.
My cat tested negative for FIV and FLV, more than 365 days ago, but has never been exposed to new cats, nor roamed outdoors since this test was performed
My cat has not, to my knowledge been tested for FIV or FLV - Please DO Test my cat/kitten
My cat has not, to my knowledge been tested for FIV or FLV - I DECLINE this test at this time
My cat is an FIV positive patient
My cat has tested positive for FLV
My cat has tested positive for Feline Heartworm's Disease
Resources - Current Dietary or Meal Plan At Home - Please Indicate Whether Your Pet’s Condition Prohibits Fasting After 9PM The Night Before Surgery
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WILL YOUR PATIENT BE ABLE TO BE FASTED AT 9PM THE NIGHT BEFORE SURGERY? ARE THERE ANY SPECIAL CONSIDERATIONS WHICH PROHIBIT FASTING SUCH AS DIABETES OR TOY BREED HYPOGLYCEMIA? WHAT IS THE NEXT MEAL BE PLAN IN RECOVERY? Please list all types of foods or treats (over the counter, prescription, homemade, or "people food"), that the patient typically receives in an average day, the amount and how it is fed. If food is left throughout the day in a feeder simply list the type and brand of food, and type "free fed" to indicate meal times
My Pet’s Pre-Anesthetic Panel
Has Not Been Performed in the Last Month-I understand it may be part of this visit today
Has Been Performed in the Last Month
Was Performed as Part of Their 4month Old Pre-Soay or Pre-Neuter Counseling
Was Performed in the Last Month At Another Clinic, I am Presenting a Copy During My Appt.
Please Perform the Following Electives During My Pet’s Pre-Anesthetic Exam
Heartworm Prevention - Send Home or Start Monthly Tablet (Dogs) Or Topical (Cats)
Heartworm Prevention - ProHeart 6 (Dogs over 6months old)
ProHeart 12 (Dogs over 1yr)
Flea or Flea Tick Prevention - Note treatment is not optional if fleas or ticks are present
Lifestage Preventative Healthcare Screen (free core vaccines)
Other
Please Perform the Following Electives During My Pet’s Anesthetic Procedure
HomeAgain TempScan Microchip
Routine Toenail Trim ($15-18)
Ear Cleaning or Flushing ($20)
Dental Cleaning or Polishing (If Time Permits-$83)
Anal Gland Expression if Needed ($22)
Other
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Next - Condition & History
Health Conditions and Health History
Prior Known Illness(es)/Surgery(ies)
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Please list any illnesses or surgeries that your pet may have on record at a facility OTHER than HIGHLAND VETERINARY CLINIC. If none or unknown to you at this time, simple state "none" or "unknown"
Chronic problems/conditions & ongoing treatment
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Please list any ongoing problems or conditions that your you are managing for your pet or treating for your pet OTHER than what is on record at HIGHLAND VETERINARY CLINIC. If none, simple state "none"
Allergy History as Diagnosed by a Veterinarian - Select all that apply
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No Known Allergies
Atopy (inhaled-Seasonal or Otherwise)
Flea Allergy
Food Allergy
Vaccine Reactivity
Patient Takes Immunotherapy or has An Allergy Plan
Other
Current Apparent Attitude/Disposition
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Bright. Alert, Responsive
Quiet, But Alert, Responsive
Depressed/Lethargic, But Aware
Vomiting?
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No
Yes, every few hours, within the last 24 hours
Yes, every so often over the last week
Yes, every few weeks, my pet vomits food.
You Indicated that Your Pet is Vomiting on an Acute or Chronic Basis - Please select all that apply
Foamy Vomit
Clear Liquid or Mucoid Vomit
Mushy, Partly Digested Food
Regurgitation - Food Pieces/Not Digested
Vomiting Water
White Vomit
Yellow Vomit
Brown Vomit
Black Vomit
Green Vomit
Objects or Material In Vomit (Describe Under "Other")
Worms in Vomit
Other
You Indicated That Your Pet Has Been Vomiting on an Acute or Chronic Basis
Please briefly describe what you think may have caused or does cause your pet to vomit, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's vomiting episode(s)
Coughing?
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My Pet isn't Coughing
My Pet is Coughing (Acute Onset)
My Pet is Coughing (Chronically-Previous Diagnosis of Disease)
You Indicated That Your Pet Has Been Coughing on an Acute or Chronic Basis
Please indicate the onset or estimate roughly how long this cough has been present. Briefly describe what you think may have caused or does cause your pet to cough, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's coughing episode(s), including times of day or after activity.
Sneezing?
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My Pet Does Not Seem To Sneeze More Often Than is Normal
My Pet Seems to Sneeze More Often Than is Normal
You Indicated That Your Pet Has Been Sneezing on an Acute or Chronic Basis
Please indicate the onset or estimate roughly how long this persistent sneeze has been present. Briefly describe what you think may have caused or does cause your pet to sneeze, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's sneezing episode(s), including times of day or after any particular event or activity occurs in the home.
Respiratory Health Screen
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My Pet Seems to Be Breathing Normally
My Pet has a Previously Diagnosed Respiratory Condition But it is Controlled/Unchanged
My Pet has a Previously Diagnosed Respiratory Condition and Their Breathing Seems to have Declined
My Pet's Making Abnormal Sounds When Breathing
My Pet's Respiratory Rate or Effort is Abnormal
Other
You Indicated That Your Pet Has Struggled with Respiratory Issues
Please indicate the onset or estimate roughly how long this abnormal condition has been present. Briefly describe what you think may have caused or does cause your pet's breathing difficulties, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's struggle to breathe or episode(s) of abnormal breathing, including times of day or after any particular event or activity occurs in or around the home.
Does anyone in the family smoke cigarettes or marijuana indoors?
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Please Select
Yes
No
We aren't really concerned with vapor pen products nor edible consumption of CBD oil or THC--just exposure to indoor second hand smoke, relative to your pet's respiratory condition(s) and treatment right now.
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Oncology Screen
My pet has no new lumps nor bumps in the skin, nor underneath the skin that concern me at this time.
My pet has a new lump or bump in the skin or underneath the skin.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we are certain there have been no changes.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we think it may have changed in character, shape or size and it needs monitoring.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we'd like a second opinion or second look.
Oncology Screen II
Your response has indicated the need to have a first time look, or fresh look at new growth or a previously diagnosed benign tumor in or under your pet's skin. Please indicate how long the growth may have been present, or what changes you've noticed in any old growths you would like examined.
Oncology Screen III
Browse Files
If you have a photo of a lesion, or lump or bump or the location on the body that you would like to upload to your pet's chart, please feel free to do so.
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Parasite Screen - I have noticed the following within the last month:
None - I have seen no parasites in relation to my pet
Unknown Parasites on the Skin
Parasites in the Stool
Fleas
Ticks
Mites
Biting Flies or Evidence of "Fly Strike"
Other
Regarding Your Pet's Appetite and Levels of Thirst
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My Pet's Appetite Seems Normal
My Pet is Drinking Normally
My Pet's Appetite Seems to Be Increased or Excessive
My Pet's Appetite Seems to Be Decreased
My Pet Has Refused all Foods and Treats for More Than 24hrs
My Pet Has Refused Water for More than 24hrs
Changes or Abnormalities in Appetite and Fluid Intake
Your response has indicated a change in your pet's appetite level or fluid intake. Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change
Regarding Your Pet's Bowel Movements
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My Pet's Bowel Movements Seem Normal in Frequency
My Pet's Bowel Movements Seem Normal in Color
My Pet's Bowel Movements Seem Normal in Consistency and Composition
My Pet's Bowel Movements have Increased in Frequency
My Pet's Bowel Movements have Decreased in Frequency
My Pet Has Not Had a Bowel Movement in More Than 24hrs
My Pet Has Been Straining to Defecate
My Pet's Stool Seems Very Hard or Dry
My Pet's Stool Seems very Soft or Lacks Shape
My Pet Has Diarrhea
My Pet's Stool Color Seems Abnormal (see above)
I haven't observed my pet's bowel movements in the last 2 to 4 days.
My Pet Seems Chronically Irregular (see comments)
Fecal Score
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Using the chart provided, please assign the most current fecal score for your pet.
Changes or Abnormalities in Bowel Movements
Your response has indicated a change or abnormalities in your pet's bowel movements . Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change
Regarding Your Pet's Urinary Movements
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My Pet's Urination Seems Normal in Frequency
My Pet's Urine Seems Normal in Color
My Pet's Urination Seems Normal in Clarity
Increased Urination (Frequency)
Increased Amount of Urine
Decreased Urination (Frequency)
Decreased Amount (Small Amounts)
Straining to Urinate
My Pet Has Not Urinated in More Than 12-24hrs
My Pet Seems to be In Pain When Urinating (Vocalizes etc)
My Pet's Urine Appears Dark To Me
My Pet's Urine Appears Cloudy to Me
I have Seen Blood in My Pet's Urine
I haven't observed my pet's urinary habit in the last 12-24hrs
My Pet is Urinating When They Are Sleeping
My Pet's Urine Seems to have a Foul or Strong Odor
My pet's housetraining or litter pan training is failing (Urinating or Defecating Inappropriately)
Other
Changes or Abnormalities in Urinary Movements
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Your response has indicated a change or abnormalities in your pet's urinary habits that you would like to address. Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change.
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Next - Pain & Mobility Screen
Pain & Mobility Screen
Gait and Mobility - Please select all that apply
My Pet is Able to Rise from Any Position without Effort or Pain
My Pet Is able To Walk and Run As Expected
My Pet Has a Previous Diagnosis Which Impairs Their Mobility but There has Been No Decline
My Pet Has a Previous Diagnosis Which Impairs Their Mobility And There Has Been a Decline
My Pet is Limping intermittently
One or More of My Pet's Limbs is Constantly Non-Weight Bearing
My Pet Rises With Some Effort and "Stiffness", But Does Not Limp
Right Foreleg Lameness or Involvement
Left Foreleg Lameness or Involvement
Right Hind Leg Lameness or Involvement
Left Hind Leg Lameness or Involvement
Pain Scale
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Using the graph above, please rate your pet's pain from 0-4, with 0 being equivalent to no pain, and 4 being the most severe pain.
Problems with Gait, Pain, or Mobility
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Your response has indicated a problem with pain, stiffness, or mobility that you would like to address. Please indicate how long this has been going on, or what circumstances you've noticed surrounding this problem.
Concerns with Behavior or Emotional Wellness
If you feel your pet may have some handling preferences that would make them more comfortable during their stay please let us know. Please let us know if your pet struggles routinely with panic, anxiety, or aggression. Please indicate how long this has been going on, or what circumstances or activities you've noticed surrounding this problem. In general, if you have any handling or preferences that you think work best for your pet you may also list or discuss them there.
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