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Referring Veterinarian

Referring Veterinarian Information

Client Information

Patient Information

Species
Canine
Feline
Avian
Other
Sex
Female
Female Spayed
Male
Male Neutered

Medical History

Please send all medical files to info@veterinarypsychiatry.com

Include all laboratory testing.

Was the last physical examination
Normal
Abnormal
Date of last Rabies Vaccination
Has any laboratory testing been done in the past 3 months?
Yes
No
Does the patient have any current or past medical problems?
Yes
No
Is the patient currently on any medications?
Yes
No
How would you describe the pet’s behavior in your office? FAS = Fear, Anxiety, and/or Stress as per Fear Free℠* (Choose one option below)
Level 5 (High) - Severe signs of FAS with aggression such as growling, lunging, barking, hissing, snarling, and/or snapping. Intolerant of procedures.
Level 4 (High) - Severe signs of FAS without aggression, such as immobility, fidgeting, escape behavior, dilated pupils, excessive panting (dog), increased respiratory rate, trembling, tense closed mouth, ears back, tail tucked or thrashing (cat). May or may not be accepting any types of reinforcers. Not interested in interacting with team members and may be showing active avoidance (moving away).
Level 3 (Moderate) - Displays more than 2 moderate signs of FAS occurring more than 4 times in a minute. May refuse reinforcements for brief moments. Might take treats roughly at times. May also be hesitant to interact with team members but not actively avoiding team members.
Level 2 (Moderate) - Displays 1 to 2 moderate signs of FAS, such as ears slightly back or to the side, tail down, furrowed brow, slow movements or overly attention seeking, and/or panting with a tighter mouth (dog), occurring 4 or less times a minute. Readily accepts reinforcement (treats, toys, and attention). Still soliciting social interactions with team members.
Level 1 (Low) - Displays 1 or 2 mild signs of FAS, such as lip licking, avoids eye contact, turns head away without moving away, lifts paw, or partially dilated pupils, and/or panting but commissures of lips are relaxed, occurring less than 4 times a minute. Interested in reinforcers (treats, play, attention) and choses to interact with the team members.
Level 0 (Low) - No signs of FAS. Pet displays relaxed body language and solicits social interactions with team members.
Don't know, I was not present at the last examination or cannot remember.
Has this animal ever shown any aggression towards you or your staff members?
Yes
No
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