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 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 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 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 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 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 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 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 Select the number that best describes the pain as it is right now 0 1 2 3 4 5 6 7 8 9 10 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 Enjoyment of Life 0 1 2 3 4 5 6 7 8 9 10 Ability to Rise to Standing From Lying Down 0 1 2 3 4 5 6 7 8 9 10 Ability to Walk 0 1 2 3 4 5 6 7 8 9 10 Ability to Run 0 1 2 3 4 5 6 7 8 9 10 Ability to Climb Stairs, Curbs, Doorsteps, etc 0 1 2 3 4 5 6 7 8 9 10 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 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
Ben Charlton Allergic Dermatitis Questionnaire Allergic Dermatitis Questionnaire A survey designed to track the progress of a pet with dermatitis. Please click the NEXT button to start the survey. If you have issues accessing this survey email [email protected] or [email protected] Thanks Select One of the following Categories based on how you feel your dog is today? Normal Dog Itching is not really a problem today Very mild itching occasional episodes of itching. The dog is slightly more itchy than before the problem began Mild itching. More frequent episodes of itching. May notice occasional episodes of itching at night. No itching when sleeping, eating, playing, exercising or when being distracted. Moderate itching. Regular episodes of itching when the dog is awake. Itching might occur at night and wake the dog. No itching when eating, playing, exercising or when being distracted Severe itching. Prolonged episodes of itching when the dog is awake. Itching occurs at night and also when eating, playing, exercising, or when otherwise distracted. Extremely severe itching. Dog is scratching, chewing, licking almost continuously. Itching practically never stops, regardless of what else is happening around the dog. How long has it been since your dog was given anti allergy medication (just select the closet answer) This only refers to medication that was given specifically to stop or treat your dogs itching. 2-3 days 1 week 2 weeks 4 weeks 6 months 1 year Has your pet experience any off the following in the past week (Select all that apply or None) Diarrhoea Vomiting ( frequency and time frame in the comment field) Lethargy Anorexia - this means they are not eating Polydipsia - Increased water consumption (please estimate in the comment field) What diet or dry food do you feed your Pet Royal Canin Anallergenic Royal Canin Hypoallergenic Royal Canin Sensitivity Control Hills Prescripton Z/D Hills Prescription D/D Hills Canine Sensitive Stomach Ivory Coat - Grain Free Adult Food (multiple types) Other(Enter details in the comment field) Please select all other medications or supplements you are also using currently. Flea/ Tick Preventative Joint Supplements - Glucosamine / Chondroitin etc Antibiotics Omega 3 Fatty Acid Supplement (eg Megaderm) Corticosteroids (Prednisilone / Macrolone) Non Steroidal pain relief ( Metacam / Carprofen / Gabapentin / Tramadol Allergy Desensitizing Vaccines Apoquel Cytopoint (if given in the last 8 weeks) Please fill in the comment box below. Thanks for completing the survey. Patient Name Owner Name Email Mobile Time's up
