• Initial Dermatology Consult Questionnaire

  • Owner Details

  • Format: (+61) 000-000-000.

  • Patient Details

  • Is your pet desexed?*

  • Current Veterinary Practice

    Please give details of your current veterinary clinic, so we can send reports and updates on your pet’s treatment and progress.
  • Do you give consent for us to request your pet's medical history from your vet?*
  • 3. Have any of the following been observed:

  • Ear Infections

  • Which ear/s are infected?*
  • Have any of the following been observed:*
  • Do any relatives of this pet have ear problems?*

  • Symptoms

  • Does your pet...*
  • If the dermatitis or ear problems have been present for some time, are the symptoms worse at certain times of the year?

  • Home Details

  • Do you have any other pets?*
  • Do any relatives of this pet have skin problems?*
  • Do any humans in the house have skin problems?*
  • Does your pet spend more time indoors or outdoors?*
  • Does your pet swim?*

  • Bathing

  • For your pet's symptoms, does bathing...*
  • How often do you bathe your pet?*

  • Insects, ticks, and fleas

  • Around when was the treatment last given?
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you see other insects in your environment?

  • General Health

  • Has there been any:*

  • Medication

  • Which of these medications does your pet receive?
  • Last date given:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Last date given:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Last date given:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Last date given:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Last date given:
     - -
    2 digit day, 2 digit month, 4 digit year

  • Diet

  • What do you normally feed your pet?*
  • What proteins do these include?*

  • What do you think could be the cause of this skin problem?

  • Should be Empty: