Pre-Visit Questionnaire Form

Date(Required)

MM slash DD slash YYYY

Owner Name(Required)

Pet Name(Required)

How would you describe your pet around other animals and people?

Does your pet have any sensitive areas that she/he does not like to have touched by you or others?

What are your pet’s favorite treats? (Please bring some for your next visit to our hospital)

Does your pet like to play with toys? If so, what kinds?

Does your pet show any reluctance to getting in the carrier or car?(Required)

Yes

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(Required)

Excited

Subdued

Reluctant

Bark/Meow

Hide

Whine

Drool

Pant

Vomit

Tremble

Urine/BM

Pace

Other

Other(Required)

Does your pet prefer

Female veterinary professional

Male veterinary professional

It doesn’t matter

Is this your pet’s first visit to the vet?(Required)

Yes

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 weight

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

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 was it and what sort of results did you experience?

Anything else you would like us to know?