Initial Dermatology Consult Questionnaire
Owner Details
Full Name
*
First Name
Last Name
Phone Number
*
Format: (+61) 000-000-000.
E-mail
*
Patient Details
Name
*
Sex
*
Species
*
Breed
*
Weight
Age
Is your pet desexed?
*
Yes
No
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.
Current Vet Clinic
*
Usual Veterinarian
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1. What is the main problem you have noticed with your pet?
*
2. At what age did you first notice the condition? (Specify years/months)
*
3. Have any of the following been observed:
Sores
Scabs
Dandruff
Hair loss
Odour
Hives
Heat
Redness
Diarrhoea
Tiredness
Weight loss
Weight gain
Depression
Ear infections
Increased appetite
Increased thirst
Ear Infections
Which ear/s are infected?
*
Left
Right
Both
Have any of the following been observed:
*
Ear discharge
Head shaking
Scratching or rubbing the ear
Redness
Head tilt
Swelling
Loss of balance
Eye movement (???)
Do any relatives of this pet have ear problems?
*
Yes
No
Don't know
Symptoms
Does your pet...
*
Rub at their face
Shake their head
Scratch at their ears
Lick or chew their paws
Scratch at their sides
Lick the stomach area
Roll on their back
Bite at the tail area
Scoot on their bottom
Eye discharge
Sneeze
Wheeze or cough
Other
If your pet is itchy, please rate the itch:
Not that itchy
1
2
3
4
5
6
7
8
9
Super itchy
10
1 is Not that itchy, 10 is Super itchy
If the dermatitis or ear problems have been present for some time, are the symptoms worse in...
What, if anything, causes a worsening of symptoms?
What helps?
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Home Details
Do you have any other pets?
*
Yes
No
What pets and how many?
*
Do any relatives of this pet have skin problems?
*
Yes
No
Don't know
Do any humans in the house have skin problems?
*
Yes
No
Does your pet spend more time indoors or outdoors?
*
Indoors
Outdoors
Does your pet swim?
*
Yes
No
How often?
Where?
What room does the pet sleep in?
*
What kind of bedding does it have?
What type of flooring do you have in your house?
*
Where do you walk your pet and how often?
*
Bathing
For your pet's symptoms, does bathing...
*
Help
Worsen
Make no difference
Unsure
What type of shampoo do you use?
How often do you bathe your pet?
*
Weekly
Monthly
Rarely
Other
Insects, ticks, and fleas
When was the last time a flea was seen on this pet?
*
When was the last time a flea was seen on your other pets?
What is the current flea treatment on this pet?
*
Around when was the treatment last given?
-
Day
-
Month
Year
Date
Is flea treatment used on your other pets?
Do you see other insects in your environment?
Mosquitoes
Ants
Moths
Cockroaches
Flies
Ticks
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General Health
Has there been any:
*
Vomiting
Diarrhoea
Mucus stools
Increased water intake
Increased appetite
Weight loss
Weight gain
Weakness
Lethargy
None of these
Other
How many times a day does your pet defecate?
*
Does your pet have any other illness? If so, please specify what medications are being prescribed:
Medication
Which of these medications does your pet receive?
Ear drops
Tablets
Ointments, lotions etc
Injections
Rinses
Other
What is the name and dose of their ear drops?
Last date given:
-
Day
-
Month
Year
Date
What is the name and dose of their tablets?
Last date given:
-
Day
-
Month
Year
Date
What is the name and dose of their ointments/lotions?
Last date given:
-
Day
-
Month
Year
Date
What is the name and dose of their injections?
Last date given:
-
Day
-
Month
Year
Date
What is the name and dose of their rinses?
Last date given:
-
Day
-
Month
Year
Date
Diet
What do you normally feed your pet?
*
Cans
Dry food
Meat
Table scraps
Chews/treats
Other
What proteins do these include?
*
Chicken
Beef
Lamb
Pork
Kangaroo
Fish
Dairy
Soy
Other
Any supplements? (eg vitamins, minerals, fatty acids, glucosamine etc)
Have you ever fed a special diet? If so, what type and for how long was this diet fed?
What do you think could be the cause of this skin problem?
Please write any ideas you might have.
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