New Patient Pre-Visit Questionnaire

New Patient Pre-Visit Questionnaire

Here at MVVHC 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. This 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 you & your pet’s preferences.
Owner's Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Pet's Name *
Species*

CanineFeline
Breed and Color*
Pet's Birthday/Age*
Please specify weeks, months, or years if providing age
Pet's Gender*

MaleFemaleNeutered MaleSpayed Female
Describe any prior illness, surgeries, reoccurring problems or other patient information:
Veterinary hospital where previous medical records are located:
Please include city and state of previous veterinary hospital. If you have the number please include as well.
Please upload any medical records or pertinent files

Browse Files

Cancelof
How would you describe your pet’s reaction to going to the veterinary hospital?*

Excited/HappySubduedFearful of veterinary staffSomewhere in between
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 car.Other pets and/or people passing by while in the reception area.Being approached by veterinary staff.Sounds coming from the back areas of the practice.Being put up on the table for examinations.Loud voices during examinations.The use of instruments such as the stethoscope or otoscope (to look in the ears).Nail TrimsEntering the veterinary hospital.Waiting with other people and animals in the waiting area.Getting on the scale for a weight.Going into the exam room.Having direct eye contact with technician and/or the veterinarian.Having a rectal temperature taken.Being taken out of the exam room for procedures.Sensitivity to face/mouth being touched.
The next 3 questions refer to your pets travel to the veterinary hosptial. This will help us determine if we need to take pre-visit measures to lower fear and anxiety prior to arrival.
How and where does your pet travel in the car?*

Carrier/KennelSeatbeltLooseOther
How does your pet behave in the car?*
Does your pet show any signs of nausea with car travel, such as drooling or vomiting?*
The next few questions help us provide a low stress, fear free experience while visiting our clinic.
How would you describe your pet around other animals and people. *
Does your pet have any sensitive areas that he/she does not like to have touched or examined by you or others?*
What are your pet's favorite treats? (Feel free to bring some to your next visit to our hospital) Note any food allergies your pet may have.*
Does your pet like to play with toys? If so what kind? (Feel free to bring some to your next visit to our hospital)*
Has your pet ever been prescribed any medications to help with a visit to the veterinary hospital? If so, please list below:*
Anything else you would like us to know?
Should be Empty: