Ben Charlton Pre Surgical Assessment The Pre Surgical Assessment is designed to help us get some background on your pet prior to surgery. Pet Name Your Name Email Address 1. Has your pet ever had a anaesthetic performed at another vet surgery? This excludes Kalinga Park Vet and Ascot Vet. If yes please enter the date and the name of the surgery where that procedure was performed. Yes No None 2. Are you aware of any condition that may affect your pets ability to tolerate an anaesethetic? (Enter details in the comment field) Yes No None 3. Has your pet had any general blood test in the past 6mths? If it wasnt done at Kalinga or Ascot please give us the details. Yes No None 4. Please enter any other relevant information about your pet and surgery you think we need to know. 5. If your pet is over 8 we will require they receive compulsory extra fluid therapy. This should have been included in any assessment. Other pets we recommend recieve extra fluid therapy - this speeds recovery times improves pet post operative well being. Do you consent to this fluid therapy? Yes No None 6. We recommend all pets recieve a blood test prior to surgery This link outlines some of the reasons we recommend this. There is additional cost of approximately 110$ for this. Do you consent to your pet having a preanaesethetic blood test? YES NO None We ask your pet not receive any food the morning they are due to have surgery. Continue to give them water but restrict all food.All pets should be presented clean and dry - if your pet has been swimming in the days prior at a creek or lake - please ensure they have been bathed in clean fresh town water to ensure no unusual bacteria remain on their coat. If you accept these conditions click below. Please fill in the comment box below. Time's up
Ben Charlton Treatment Assessment Questionnaire Welcome to your Pain Assessment Questionnaire Select the one number that best describes the pain at its worst in the last 7 days.0 is none, 10 is extreme 0 1 2 3 4 5 6 7 8 9 10 None Select the number that best describes the pain at its least in the last 7 days (0 is none , 10 is extreme pain) 0 1 2 3 4 5 6 7 8 9 10 None Select the number that best describes the pain at its average in the last 7 days. 0 1 2 3 4 5 6 7 8 9 10 None Select the number that best describes the pain as it is right now 0 1 2 3 4 5 6 7 8 9 10 None Description of function: 0 = doesnt intefer , 10 = completely interfers Fill in the oval next to the one number that best describes how during the last 7 days pain has interfered with your dog's: General Activities 0 1 2 3 4 5 6 7 8 9 10 None Enjoyment of Life 0 1 2 3 4 5 6 7 8 9 10 None Ability to Rise to Standing From Lying Down 0 1 2 3 4 5 6 7 8 9 10 None Ability to Walk 0 1 2 3 4 5 6 7 8 9 10 None Ability to Run 0 1 2 3 4 5 6 7 8 9 10 None Ability to Climb Stairs, Curbs, Doorsteps, etc 0 1 2 3 4 5 6 7 8 9 10 None Overall impression: Select number that best describes your dog's overall quality of life over the last 7 days 0 1 2 3 4 5 6 7 8 9 10 None Fill in the captcha Please enter any other notes you might have regarding your Pet's condition Patient Name Client Name Email Mobile Phone Time's up
