Dallas Veterinary Clinic - Pre Visit Questionnaire Check-in Form

1
Date* This field is required.
Date
Year
Month
Day
2
* This field is required.
Client's Name
Please enter your phone
Email
Pet's Name
3
As Fear Free Certified Professionals, we want to make your 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 and your pet’s preferences.
4
Does your pet show any reluctance to getting in the carrier or car?* This field is required.
Yes
No
5
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc)* This field is required.
6
During travel to the veterinary hospital, does your pet do any of the following* This field is required.
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
Other
None
7
Does your pet prefer* This field is required.
Female veterinary professional
Male veterinary professional
It Doesn't Matter
8
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.* This field is required.
Getting in their carrier or the car
Going into the exam room
Entering the veterinary hospital
Being put up on the table for examination
Other pets and /or people passing by while in reception/check-in
Having direct eye contact with the technician and/or veterinarian
Waiting with other people and animals in the waiting area
Loud voices during examination
Being approached by veterinary staff
Having a rectal temperature taken
Getting on the scale for a weight
The use of instruments such as the stethoscope or otoscope(to look in the ears)
Hearing the doorbell, overhead intercom. or phones ringing
Being taken out of the exam room for procedures
Sounds coming from the back areas of the practice
None
9
How would you describe your pet around other animal and people?* This field is required.
10
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?* This field is required.
11
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 your pet reach?* This field is required.
12
What are your pet's favorite treats? (Please bring some to your next visit to our hospital)* This field is required.
13
Does your pet like to play with toys? If so, what kinds?* This field is required.
14
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?* This field is required.
15
Anything else you would like us to know?
Should be Empty: