FEAR FREE PRE-VISIT QUESTIONNAIRE

FEAR FREE PRE-VISIT QUESTIONNAIRE

Please fill out one form per pet in your family.
Date:

MonthDayYear
Date
Client First & Last Name:*
Pet Name:*
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.
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/MeowWhinePantTremblePaceNone of the aboveOther
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 hospitalOther pets and/or people passing by while in reception/check-inWaiting with other people and animals in the waiting areaBeing approached by veterinary staffGetting on the scale for a weightHearing the doorbell, overhead intercom, or phones ringingSounds coming from the back areas of the practiceGoing into the exam roomBeing put up on the table for examinationHaving direct eye contact with the technician and/or veterinarianLoud voices during examinationHaving a rectal temperature takenThe use of instruments such as the stethoscope or otoscope (to look in the ears)Being taken out of the exam room for proceduresNone
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 your 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?*
Anything else you would like us to know?

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VETERINARY HEALTHCARE TEAM: Transfer all applicable information from questionnaire to the patient’s Fear Free Emotional Medical Record.
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