Fillable FEAR FREE EMOTIONAL MEDICAL RECORD

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FEAR FREE EMOTIONAL MEDICAL RECORD

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Country of origin: OTHERS
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Patient Name: _________________________________________________________________________________________________________________
Pre-Visit FAS Management Interventions
Motion Sickness Medication
In-Hospital Sedation
Compression Garment
PVP
Analgesia
Calming Music
PVN
Pheromones
Other:
________________________________________________
Preferred Healthcare Provider
No Preference Female Male
Preferred Entrance to Practice
Likes (prevents/alleviates FAS):
________________________________________________________________________________________________
Normal Alternate Entrance Wait Outside/In Car Other:
_____________________________________
Preferred Distraction Techniques
Food:
_____________________________________________________________________________________________________________________
Toy:
______________________________________________________________________________________________________________________
Petting/Brushing:
__________________________________________________________________________________________________________
Other:
____________________________________________________________________________________________________________________
Preferred Location for Exam
Floor
Lap
Carrier
Table
Baby Scale
Other:
______________________________________________________________________________
Behavior Management Products
Towel
Calming Cap
Blanket
Other:
______________________________________________________________________________________________
Cat MaskBasket Muzzle
Triggers (increases FAS):
________________________________________________________________________________________________________
FEAR FREE EMOTIONAL MEDICAL RECORD
In-Hospital Sedation
FAS Scores (Circle All That Apply)
Medication:
_________________________
Reception Area
Scale
Examination
Carrier Door Opened
Treatment Area
Boarding/Hospitalization
Other:
________________________
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Dose:
________________________________
Route of Administration:
________________________
RED (STOP)
GREEN (GO) YELLOW (CAUTION)
© 2019 Fear Free, LLC
FEAR FREE EMOTIONAL MEDICAL RECORD
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FEAR FREE EMOTIONAL MEDICAL RECORD

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Completed 18 February 2021

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