IMPORTANT INFORMATION

Please take the time to complete this questionnaire as thoroughly as possible prior to your pet's visit for a skin issue. Because the skin has only so many manifestations of disease, multiple inciting causes can produce the exact same lesions. For this reason, we often heavily rely on a patients history and pattern of progression to determine which diagnostic steps and treatment options might be most important first. What you have been noticing at home can significantly influence our plan even prior to your arrival. This will be especially important for pets that have particularly long histories so please be as specific as possible in describing what you are seeing and what you have seen at home over time.  The form may take some time to complete but it is a worthwhile investment in the health and treatment of your beloved companion.

Form - Dermatology Questionnaire Form

Client Name: (required)

Patient Name: (required)

Patient Status: (required)
Intact Male
Neutered Male
Intact Female
Spayed Female

Patient Breed: (required)

Date of Appointment: (required)

Reason for current visit (i.e. Itching, hives, dry skin, hair loss etc.), be specific: (required)

If itching is part of the current issue, how would you grade the severity on a scale of 1 to 10
with 1 being barely itchy to 10 being incessantly itchy?

Has the itching been constant, waxing and waning, seasonal etc.?

Describe the type of skin changes or lesions you are noticing, if any (i.e. redness, pustules
pimples, hives, crusting etc.):

How long have skin issues/changes/lesions been present?

What bodily areas are currently involved?

Are any other signs of illness present (i.e. vomiting, diarrhea, lethargy etc.)?

Does your pet have a history of previous skin problems/changes/lesions etc.?
Please comment even if previous issues seemed to have fully resolved.

If Yes to history of problems, What age were the very first signs noted?

If Yes to history of problems,what type of issues, skin changes, lesions did you notice in the past
and what bodily areas were affected? Please compare the past changes/lesions to the current ones.

Have lesions seemed to start in one place and gradually spread to other spots?
If yes, describe the pattern.

What treatment/medication(s) have been tried in the past and was any improvement noted during
specific treatment(s)/medication(s)?

Has the skin ever been normal since the first onset of signs?

Have any diet changes been made recently/around the time of the onset of skin signs?

Have any changes in life style/environment occurred around the time of the onset of signs (i.e. My
pet has always been primarily indoors but recently started going outdoors/spending more time
outdoors; new carpet deodorizer is being used etc.)?

Does your pet have any history of travel outside of this general area
(i.e. South-east, mid-west etc.)?

Are any other pets or humans in the household showing any dermatological signs?
If yes, are they similar or different than the pet we are currently seeing?

Is your pet currently on any medications, supplements, preventatives etc.?
Please be specific.

Any other specific comments/concerns regarding the skin or otherwise:


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