Dermatology Questionnaire
Your Name
*
First Name
Last Name
Pet's Name
*
Pet's most recent weight in pounds (if you know it)
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?
*
Has your pet been seen by another veterinarian within the last two months?
*
Please Select
YES
NO
Please list all hospitals/veterinarians that have seen your pet
*
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?
*
Was the onset of signs:
Sudden without warning
Gradual, became worse over time
If gradual, describe how:
Where on the body did the skin problem start?
How did the skin look in the beginning? Was there a rash or hair loss first?
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:
Previous diagnostic test for skin disease and results:
Previous NON-skin diseases, treatment, results:
List any medications 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 your pet received an oral or injectable steroid?
When was the last time your pet received an oral or injectable antihistamine?
Is your pet on flea/heartworm preventatives?
Please Select
Yes
NO
What months do you administer these preventatives?
When was the last time you administered these preventatives?
Cats only: Does your cat do better with tablet or liquid forms of medications?
Please Select
tablet
liquid
How does you pet do if you need to bathe him/her?
Describe animal’s environment, indoor % and outdoor %:
Example: 90% indoor. 10% outdoor
Has your pet travelled outside of the state/country
Please Select
Yes
No
If yes, to where and when?
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)
*
If yes, please describe
Has your pet had any recent or chronic digestive problems?
Please Select
Yes
No
We may use images of our patients on our social media platforms. Please alert our team during your appointment if you do not want your pet's image posted.
Submit
Should be Empty: