Dermatological Exam - Virtual Check-In
Hello! Please help us expedite your check-in process, decrease your wait time, duplication of services and increase our capacity to troubleshoot your pet's dermatological problem, and offer you the best skin care, by completing this history form prior to your appointment. You can complete it by yourself, with other family members or in the office, but with a little advance planning we can help lead your attending DVM to develop the best plan for your pet's ongoing healthcare.
Pet's Primary Adult Caregiver - Full Name
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First Name
Last Name
Pet's Other Adult Caregiver(s) if Any
Name(s)
Valid Caregiver E-mail
Pet Patient's Name
*
Appt Date If Known
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Month
-
Day
Year
Date
If different than the caregiver(s) listed above, who is the adult person presenting this pet patient to Highland during the appointment/check in time?
First Name
Last Name
Primary Goal for today's visit
*
List your understanding of the purpose of this appointment or visit, and/or any questions you have about the appointment.
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Next - General Information
GENERAL INFORMATION
Patient Species
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Canine (Dog)
Feline (Cat)
Date of Birth (Estimate Ok)
Please select a month
January
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Month
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Day
Please select a year
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Year
Age of Patient - Estimate Ok
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Indicate above how old your pet may be in terms of weeks, months, or years
Pet's Biological Gender & Reproductive Status
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Male - Intact, less than 1yr old
Male - Intact, >3yrs old
Female, Intact, less than 1yr old
Female, Intact >3yr old
Neutered Male
Spayed Female
Female - Spayed Status Unknown
Name of veterinarian or other preferred veterinary professionals you have most recently seen or are currently seeing
Lifestyle
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Indoor Exclusively (uses litter pan or pee-pad to eliminate)
Indoor/Lanai
Indoor/Outdoor to Eliminate or Exercise
Outdoor Mostly or Exclusively
Canine Activities or Occupation
My Dog is a Companion or Pet
Doggie Daycare
Visits Pet Store
Visits or Stays in Home with Different Pets
Pets from Other Houses Frequent Our Home
Attends Dog Park
Goes to Puppy School/Class or Adult Obedience Training
Attends Boarding or Grooming Facilities
Competes in Organized Agility, Hunting or Herding
Competes in Shows
Travels with the Family
Hunts/Hikes/Goes Fishing or Camping
My Dog Likes to Swim
We Feed our Pet(s) Outdoors
My Dog is a Working Animal : Guardian, Hunting, Herding or Rescue
My Pet is a Working Animal: Medical or Emotional Support
This Patient Lives in an Institution (such as a nursing care facility or school)
This is a Foster Animal
We Foster other Animals
Patient is or will be a Breeding Animal
Other
Feline Activities or Occupation
At Home Exclusively (Pet Sitter Only if We are Away)
Visits or Stays in Home with Different Pets
Pets from Other Houses Frequent Our Home
Visits Pet Store (i.e. PetSmart Window)
Goes to Kitten Socialization Class
Attends Boarding or Grooming Facilities
Competes in Shows
Travels with the Family
We Feed our Pet(s) Outdoors
My Pet is a Working Animal: Medical or Emotional Support
This Patient Lives in an Institution (such as a nursing care facility or school)
This is a Foster Animal
Companion or Pet Cat
We Foster other Animals
Barn Cat
Patient is or will be a Breeding Animal
Patient is a Proven Mouser
Lifestyle I - Surrounding Environment
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Suburban (Neighborhood - Some trees and wildlife)
Urban (Cityscape/Downtown - Lots of Concrete)
Rural (Some Acreage, Some Wildlife, Maybe Livestock)
The American Animal Hospital Association advises us to personalize your pet's health risk assessment to prevent infectious diseases, external or internal parasites, or treat infectious illness that may be more prevalent based on your homes surrounding ecosystem, climate, and exposure to housemates or wildlife which may contact the grass and dirt of your yard. Please select the option that best matches your surrounding location.
Lifestyle III - Water Borne Illness/Injury
There is no body of water (large or small) within twenty feet of my home and my pet will not have contact with any body of water
My pet is a foster pet or newly adopted as a stray its history is unknown
There is a body of water (large or small) within twenty feet of my home (mosquito flight distance), but my pet will not have physical contact with the water.
My pet may have contact sometimes with a body of standing water
Lifestyle II - Housemates and Animal Neighbors
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Other pets - Dog(s)
Other pets - Cat(s)
Other pet(s) - Small Mammals
Livestock on Property - No Interaction
LIvestock on Property - Minimal or Moderate Interaction
Family Feeds Feral Cats or Stray Animals
Racoons are trees or yard on occasion
Squirrels, Skunks, or Other Small Mammals
Wild Canines (Coyotes or Foxes)
Deer in Yard
Wild Turkeys in Yard
None or N/A
Other
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Next - Resources
Resources
Medication I
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My pet is currently taking, or is routinely prescribed prescription medication other than routine prevention (i.e. vaccines, heartworm/flea/tick prevention)
My pet is not taking nor are they prescribed any medications other than routine prevention (i.e. vaccines, or heartworm/flea/tick prevention)
Medication II
Please list all routinely prescribed medication other than routine prevention and please state the most recent successful dose or in clinic administration (date and or time)
Medication III
I will need refills of this medication today, or soon
I need help with compliance--this medication is difficult to give or fit in with our routine (i.e. compounded to flavored liquid, chewable tablet, or topical if possible)
I would like this medication sent to our door via your online pharmacy
Vitamins, Supplements, Over-the-Counter Remedies or Medications
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My Pet Does Not Take Vitamins, Supplements, or OTC Medications
My Pet Takes Vitamins, Supplements or OTC Medications
I Need Refills or Guidance from The Clinic
My pet takes an over the counter flea/tick preventative
If available, would like these OTC medications sent to our door via your online pharmacy
Vitamins, Supplements, Over-the-Counter Remedies or Medications II
Please list all OTC medications, preventatives, vitamins or nutritional/herbal supplements or remedies that your pet takes at home.
My Dog's External Parasite Prevention (Flea/Tick Etc) of Choice is:
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Bravecto 3 Month Tablet - https://tinyurl.com/HVCBravecto
Provecta Advanced - https://provectapet.com/
Simparica Trio - https://tinyurl.com/HVCsimparicatrio
Revolution Monthly Topical https://www.zoetispetcare.com/products/revolution
My dog is not on external parasite prevention currently
Other
My Cat's Parasite Prevention (Flea/Tick, Heartworm, Ear Mites Etc) of Choice is:
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Bravecto 2 Month Topical Solution - https://tinyurl.com/HVCCatBravecto
Provecta II for Cats- https://provectapet.com/
Revolution or Revolution Plus - https://www.zoetispetcare.com/products/revolution-plus
My cat is not on any parasite prevention
Other
My Dog's External Parasite Prevention (Flea/Tick, Etc) II
If possible, I would like refills from your online pharmacy and prescription management system: https://tinyurl.com/HVCcovetrusFleaTick
My Cat's Parasite Prevention (Heartworm, Flea/Tick, Etc) II
If possible, I would like refills from your online pharmacy and prescription management system: https://tinyurl.com/HVCcovetrusCatPara
External Parasite Prevention - Housemates - Which Pets Are Treated?
*
There are no other pets in the home
Dog(s)
Cat(s)
Small Mammals (Ferrets, Rabbits, Rodents)
External Parasite Prevention - Housemates II - Which Pets Are NOT Treated
Please list any of the pets indicated above who are NOT receiving flea or tick prevention at this time.
Resources - Current Dietary or Meal Plan At Home
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Please list all types of foods or treats (over the counter, prescription, homemade, or "people food"), that the patient receives in an average day or week. For each food or treat, please list the amount the patient receives on an average day or week, and the times during the day that your patient receives a meal. If food is left throughout the day in a feeder simply list the type and brand of food, and type "free fed" to indicate meal times.
Current Protein Sources (Including from Carbohydrates) and Dietary Plan
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Please list all types of animal and plant ingreditents listed in the foods or treats (over the counter, prescription, homemade, or "people food"), that the patient receives and eats. Include chews such as rawhides or animal chews.
Resources - Current Dietary or Meal Plan at Home - Dog
My Pet's Diet is currently a Prescription Diet, and I am interested in receiving it through home delivery via: https://tinyurl.com/HVCpharm
Resources - Current Dietary or Meal Plan at Home - Cat
My Pet's Diet is currently a Prescription Diet, and I am interested in receiving it at home via: https://tinyurl.com/HVCpharm
Resources - Food & Water Vessels - Cat
My cat eats or drinks from a plastic bowl
My cat eats or drinks from a ceramic bowl
My cat eats or drinks from a metal bowl
Other
Resources - Sleeping Quarters & Habits
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How many hours of the day does your pet receive rest, on average, and where does your pet sleep. Please indicate the type or material (cotton, down, etc) your pet rests upon and how often it is laundered. Please indicated whether your pet is sleeping more or less in a way that concerns you. If your pet is unable to get adequate rest, please discuss that here (i.e. pacing/itching/whining etc). If your pet is older than 8yo please indicate whether your pet is overactive and rests less.
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Next - Condition & History
Health History and Dermatological Condition
Prior Known Illness(es)/Surgery(ies)
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Please list any illnesses or surgeries that your pet may have on record at a facility OTHER than HIGHLAND VETERINARY CLINIC. If none or unknown to you at this time, simple state "none" or "unknown"
Chronic problems/conditions & ongoing treatment
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Please list any ongoing problems or conditions that your you are managing for your pet or treating for your pet OTHER than what is on record at HIGHLAND VETERINARY CLINIC. If none, simple state "none"
When, to your knowledge was your pet's last Heat Cycle?
If you have never observed a heat cycle, simply state "unknown"
Allergy History If any as Diagnosed by a Veterinarian - Select all that apply
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No Known Allergies
Atopy (inhaled-Seasonal or Otherwise)
Flea Allergy
Food Allergy
Vaccine Reactivity
Patient Takes Immunotherapy or has An Allergy Plan
Other
Vomiting?
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No
Yes, every few hours, within the last 24 hours
Yes, every so often over the last week
Yes, every few weeks, my pet vomits food.
You Indicated That Your Pet Has Been Vomiting on an Acute or Chronic Basis
Please briefly describe what you think may have caused or does cause your pet to vomit, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's vomiting episode(s)
Does anyone in the family smoke cigarettes or tobacco indoors?
*
Please Select
Yes
No
We aren't really concerned with vapor pen products nor edible consumption of CBD oil or THC--just exposure to indoor second hand smoke, relative to your pet's skin condition(s) or allergy treatment right now.
Is the Patient Exposed to Feathers?
*
Please Select
Yes
No
Unsure
Do you know if any of the pet's close genetic relatives have skin problems?
*
Please Select
Yes
No
Unsure
Is the Patient Exposed to Indoor Plants?
If so, Please List
Do Other Pets in the House Seem to be effected?
*
Please Select
Yes
No
Unsure
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Next
Using the chart above please rate your pet's level of itching or self grooming at this time.
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0
1
2
3
4
5
6
7
8
9
10
Normal or None
Severe Itching
0 is Normal or None, 10 is Severe Itching
What area of your pet's body are involved in this dermatological event? Please select al that apply today.
*
Ears
Rump/Tail
Trunk/Back
Head/Face
Belly/Chest
Feet/Between Toes
Front Leg(s)/Elbows
Other
Ear Condition - Please Select all that apply
Discharge noted in or around ears?
Foul odor from ears or face area?
Head shaking or ear scratching/rubbing?
Hearing loss noted?
Pain when ears are touched?
Swelling or redness of ear pinnas?
Describe Itching or Excessive Self Grooming Pattern
If your pet is experiencing a level of itch beyond the level of 2, please indicate the onset or estimate roughly how long this itching condition has been present. Briefly describe what you think may have caused or does cause your pet to itch, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's itching or episode(s) of chronic itching, including exposure to any plants, other animals, seasons, proteins or carbohydrate sources.
Any New or Chronic Hair Loss Noted? Please select al that apply today.
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None
General Hair Loss
Patchy Hair Loss
Top Coat Primarily
Undercoat Primarily
Facial Hair Loss (i.e. around eyes)
Other
Any Dandruff Present?
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No
Yes
Unsure
Odor, pigment, or texture change to skin or coat?
Please describe to the best of your ability any changes that you have noticed or that have concerned you.
Patient's most recent skin scraping or cytology?
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Please state the most recent date of this laboratory procedure. If patient has has never had a skin scraping nor cytology (including ear swab) please state "none" or "unknown"
Has your pet, to your knowledge ever received allergy testing through Spectrum, Greer Labs, or VDI Laboratories
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Please state the most recent date of this laboratory procedure. If patient has has never had a skin scraping nor cytology (including ear swab) please state "none" or "unknown"
Has your pet, to your knowledge ever received had thyroid testing or cortisol testing
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Please state the most recent date of this laboratory procedure. If patient has has never had an endocrinology test type "none" or "unknown"
Signs of Problem Is Worse
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Unsure
Indoors
Outdoors
Other
Seasonal Patterns: f your pet has had this problem, or related skin problems, please state whether you've notice it
Year Round
Winter
Spring
Summer
Fall
Pet's Most Recent Medications or Treatments - Select all that apply
Steroid (Depo-Medrol, Prednisone, Prednisolone, Dexamethasone)
Apoquel Tablets
Cytopoint Injection
Cyclosporine/Atopica
Topical Therapy - Spray
Topical Therapy - Shampoo
Topical Therapy - Ears
Oral Anti-Fungals (Ketoconazole etc)
Oral Anti-biotics (Cefpodoxime, etc)
Cold-Laser Therapy
Acupuncture
Supplements
Other
What was the response level of these treatments?
Please comment the time period between treatements if you've had any successful therapies that we would not have on record. To the best of your ability, please describe what you think has worked best for your pet, any difficulty you've had accessing the most successful therapies, etc. so we can help as best we can.
Patient Hygiene or Grooming Practices
*
Please comment when the patient was last bathed or groomed and by whom, describe the product used, and the water temperature if known.
Oncology Screen
My pet has no new lumps nor bumps in the skin, nor underneath the skin that concern me at this time.
My pet has a new lump or bump in the skin or underneath the skin.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we are certain there have been no changes.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we think it may have changed in character, shape or size and it needs monitoring.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we'd like a second opinion or second look.
Oncology Screen II
Your response has indicated the need to have a first time look, or fresh look at new growth or a previously diagnosed benign tumor in or under your pet's skin. Please indicate how long the growth may have been present, or what changes you've noticed in any old growths you would like examined.
Oncology Screen III
Browse Files
If you have a photo of a lesion, or lump or bump that you would like to upload to your pet's chart, please feel free to do so.
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Parasite Screen - I have noticed the following within the two months:
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None - I have seen no parasites in relation to my pet
Unknown Parasites on the Skin
Parasites in the Stool
Fleas
Ticks
Mites
Biting Flies or Evidence of "Fly Strike"
Other
Date of most recent flea/tick/mite treatment
*
If none known type "none" or "unknown"
Regarding Your Pet's Bowel Movements
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My Pet's Bowel Movements Seem Normal in Frequency
My Pet's Bowel Movements Seem Normal in Color
My Pet's Bowel Movements Seem Normal in Consistency and Composition
My Pet's Bowel Movements have Increased in Frequency
My Pet's Bowel Movements have Decreased in Frequency
My Pet Has Not Had a Bowel Movement in More Than 24hrs
My Pet Has Been Straining to Defecate
My Pet's Stool Seems Very Hard or Dry
My Pet's Stool Seems very Soft or Lacks Shape
My Pet Has Diarrhea
My Pet's Stool Color Seems Abnormal (see above)
I haven't observed my pet's bowel movements in the last 2 to 4 days.
My Pet Seems Chronically Irregular (see comments)
Fecal Score
*
Using the chart provided, please assign the most current fecal score for your pet.
Changes or Abnormalities in Bowel Movements
Your response has indicated a change or abnormalities in your pet's bowel movements . Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change
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Next - Patient Anxiety Screen & Finish
Patient Behavior & Finish
Sometimes changes in a pet's behavior can indicate pain, illness, or injury. We have just a few more questions to ensure that we have as much information we can use to help your pet. Remember they can't speak and tell us what's wrong, so we count on you and thank you for your patience!
Behavioral Screen
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My Pet is Acting and Behaving Normally, In General, For Him/Herself
My Pet does Not Seem to Have Any Troubling Behaviors That I Would Like to Discuss
My Pet Seems Generally More Anxious Than Normal
My Pet Has Developed a Phobia or Specific Anxiety I would like to Discuss
Separation Anxiety - My Pet Destroys My Property, Causes Self Harm, or Vocalizes Excessively When I Am Gone from the House
My Pet Has Noise Phobia
Other
Concerns with Behavior or Emotional Wellness
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Your response has indicated your pet may have a struggle with his/her emotional wellness or have a behavioral concern that you would like to address, or that may help us handle your pet's care as comfortably as possible. Please indicate how long this has been going on, or what circumstances or activities you've noticed surrounding this problem. In general, if you have any handling or preferences that you think work best for your pet you may also list or discuss them there.
Medical Progress Photo or Video
Browse Files
If you have a photo, video, or file which you feel is relevant to your visit today, please upload here
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