Pre-Visit Questionnaire

PRE-VISIT QUESTIONNAIRE
Date:

MonthDayYear
Date
Client Name:

First NameLast Name
Pet's Name:Name
As a Fear Free Certified Professional team, we want to make you pet’s veterinary experience as enjoyable and as stress free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your & your pet’s preferences.
Does your pet show any reluctance to getting in the carrier or car?

YesNo
How and where does your pet travel in the car (carrier, seatbelt, loose, etc)?:
During travel to the veterinary hospital, does your pet do any of the following:

Eager & excitedReluctantHideDroolVomitUrine/BMSubduedBark/MeowWhinePantTremblePaceOther
Does your pet prefer:

Female veterinary professionalMale veterinary professionalIt doesn't matter
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end:

Getting in their carrier or the carEntering the veterinary hospitalGoing into the exam roomOther pets and/or people passing by while in reception/check-inBeing put up on the table for examinationWaiting with other people and animals in the waiting areaHaving direct eye contact with the technician and/or veterinarianBeing approached by veterinary staffLoud voices during examinationGetting on the scale for a weightHaving a rectal temperature takenHearing the doorbell, overhead intercom, or phones ringingThe use of instruments such as the stethoscope or otoscope (to look in the ears)Sounds coming from the back areas of the practiceBeing taken out of the exam room for procedures
How would you describe your pet around other animals and people?
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw):
If so, how did you pet react?
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
Does your pet like to play with toys? If so what kinds?
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?
If so, what was it and what sort of results did you experience?
Anything else you would like us to know?
VETERINARY HEALTHCARE TEAM: Transfer all applicable information form questionnaire to the patient’s Fear Free Emotional Medical Record.
Should be Empty:

PRE-VISIT QUESTIONNAIRE