Dermatology Questionnaire
Your Name
*
First Name
Last Name
Pet's Name
*
Phone Number
*
Email
*
example@example.com
What are your goals for this appointment?
*
What else should we know about your pet to help create a fear free environment?
*
Example: Doesn't get along with other dogs
What is the reason for your visit?
*
When was your pet last seen by a veterinarian? What date and where?
*
Please list all hospitals/veterinarians that have seen your pet
*
Include all emergency, specialty or GP clinics
Is this the first time your pet has experienced these signs?
*
Please Select
Yes
No
If no, at what age did the signs first occur?
If no, has it occurred around the same time of year each time?
If no, approximate time of year symptoms occur?
Spring
Summer
Fall
Winter
How long have the current signs been going on?
*
Were the signs:
Sudden without warning
Gradual, became worse over time
If gradual, describe signs
Where on the body did the skin problem start?
How did the skin look in the beginning? Please describe
Examples: redness, rash, lesions, hair loss, etc.
Have you noticed your pet?
Rubbing
Head shaking
Scratching at ears
Grooming body excessively
Licking
Scooting
Chewing
Frequency?
Constant
Sporadic
Nightly
On a scale of 0-10 with 0 being not itchy and 10 tremendously itchy, how itchy is your pet:
*
List NA if your pet does not show signs of itch
What date did you pet have bloodwork done last? If known, also list the type of bloodwork ran, date done and where.
Previous diagnostic test for skin disease and results:
Previous NON-skin diseases, treatment, results:
List any medications, topicals, or supplements you have used on your pets (including shampoos, ointments, and OTC products):
*
Last time any medications were given:
Please list any current medications, include dosages:
Have any of the above medications helped?
Please Select
Yes
No
If so, which ones?
When was the last time (date) your pet received an oral or injectable steroid?
When was the last time (date) your pet received an oral or injectable antihistamine?
Is your pet on flea/heartworm preventatives?
Please Select
Yes
NO
Name of preventative
What months do you administer these preventatives?
Please Select
Year Round
Seasonally
Other
Please specify if other
When was the last time (date) you administered these preventatives?
Cats only: Does your cat do better with tablet or liquid forms of medications?
Please Select
tablet
liquid
How does your pet do if you need to bathe him/her?
*
Describe animal’s environment, indoor % and outdoor %:
*
Example: 90% indoor. 10% outdoor
Has your pet traveled outside of Colorado?
*
Please Select
Yes
No
If yes, when and where?
Do you have any other pets?
*
Please Select
Yes
No
If yes, what kind(s)?
Are any other pets in the household affected with a skin problem?
Please Select
Yes
No
Are any humans in the household affected with a skin problem
*
Please Select
Yes
No
Current diet (Brand, Amount, Frequency)
*
Has your pet had any recent or chronic digestive problems?
*
Please Select
Yes
No
Submit
Should be Empty: