FEAR FREE PRE-VISIT QUESTIONNAIRE

FEAR FREE PRE-VISIT QUESTIONNAIRE

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

Month Day Year
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? *

Yes No
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 & excited Reluctant Hide Drool Vomit Urine/BM Subdued Bark/Meow Whine Pant Tremble Pace
Does your pet prefer: *

Female veterinary professional Male veterinary professional It 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 car Entering the veterinary hospital Other pets and/or people passing by while in reception/check-in Waiting with other people and animals in the waiting area Being approached by veterinary staff Getting on the scale for a weight Hearing the doorbell, overhead intercom, or phones ringing Sounds coming from the back areas of the practice Going into the exam room Being put up on the table for examination Having direct eye contact with the technician and/or veterinarian Loud voices during examination Having a rectal temperature taken The use of instruments such as the stethoscope or otoscope (to look in the ears) Being 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 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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