Veterinary Dermatology Patient History Questionnaire
Please complete this questionnaire based on the PDF layout. Recreate the charts and tables so selections can be marked with an X.
Client and Pet Information
Date
*
-
Month
-
Day
Year
Date
Owner’s Name
*
Pet’s Name
*
Presenting complaint
*
How long has the problem been present?
How old was your pet when the problem started?
When the problem started, did it start suddenly or gradually over a period of time?
What did the skin or ear problem look like initially?
How has it changed or spread?
Have the problems been
Intermittent
Continuous
Both
Is the problem worse during certain times of the year? If so, when?
Itchiness in the last month (1–10)
Current Care, Diet, Bathing, and Environment
Is your pet receiving any treatment now? If yes, what kind?
Is your pet receiving any medication currently? If yes, what medication?
What do you feed your pet currently?
Have you tried different diets in the past? If so, please name the brand and how long you fed it
How often do you usually bathe your pet?
Bathing product (With what?)
Do you routinely use heartworm, flea or tick prevention products on your pet? If so, which one(s)?
Please Select
Yes
No
Sometimes
Which heartworm, flea or tick prevention products?
How old was your pet when you obtained him/her?
Where was your pet obtained?
Are there other pets in the household?
Do any of the other pets have skin problems?
Please Select
Yes
No
Not sure
Do the humans in the house have skin problems?
Please Select
Yes
No
Not sure
Percentage of the day indoors
Percentage of the day outdoors
Other diagnosed medical problems (besides skin disease)
Other helpful information
Symptom Frequency and Severity Matrix
Symptom Frequency and Severity Matrix
*
Rows
Never Occurs / None
Occurs Rarely / Slight
Occurs Occasionally / Moderate
Occurs Often / Severe
Itching (pruritus)
Excessive licking
Excessive chewing
Biting or nibbling at skin
Rubbing face or body
Scooting
Redness
Rash or bumps
Hair loss
Scabs or crusts
Flaky skin / dandruff
Oily skin or coat
Foul odor from skin
Ear scratching
Head shaking
Ear redness or discharge
Paw licking or chewing
Hot spots
Hives
Swelling of skin
Skin thickening or darkening
Open sores or raw skin
Other skin irritation
Itch Severity by Body Area Matrix
Itch Severity by Body Area
*
Rows
Not Itchy
Mildly Itchy
Moderately Itchy
Severely Itchy
Face
Ears
Neck
Axillae (Armpits)
Belly
Groin
Front Legs
Back Legs
Paws
Treatment and Medication Response Matrix
Treatment and Medication Response Matrix
Rows
Was it ever given?
Did it help?
Cortisone pills or shots (steroids, Temaril P, prednisone, Vetalog, anti-itch pills)
Antibiotics
Antihistamines (Benadryl, Zyrtec)
Antifungal medications (ketoconazole, etc.)
Modified Cyclosporine (Atopica)
Apoquel, Zenrelia, Numelvi
Allergy shots/immunotherapy
Cytopoint injections
Photo Permission Consent
I agree that AADCI may use photographs of my pet with our without my name for any lawful purpose, including such purposes as teaching, publications, illustration, advertising and internet content.
Permission to Photograph
*
Printed Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: