Fear Free Emotional Medical Record and Pre-Visit Questionnaire

Date *:

Client Name*:

Pet's Name*:

Does your pet show any reluctance to getting in the carrier or car?* -select- Yes No

During travel to the veterinary hospital, does your pet do any of the following:
Eager & excited
Subdued
Reluctant
Bark/Meow
Hide
Whine
Drool
Pant
Tremble
Urine/BM
Pace
Other

Check any situations listed below that your pet has shown avoidance or dislike in the past:
Getting in the car/carrier
Entering the veterinary hospital
Other pets and/or people passing by while in reception
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?*

Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what is the name/strength/dosage form of the medication(s) and what sort of results did you experience?*

Anything else you would like us to know?

Pre-visit FAS Management Interventions
Motion Sickness Medication
In-Hospital Sedation
Compression Garment
PVP
PVN
Analgesia
Calming Music
Pheromones
Other

Preferred Entrance to Practice
Normal
Alternate Entrance
Wait Outside/In Car
Other

Likes (prevents/alleviates Fear, Anxiety and Stress):*

Triggers (increases Fear, Anxiety and Stress)*:

In-Hospital Sedation

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