Animal Dermatology Clinic of BC

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Certified Specialist in Skin, Ears, Hair, Nails and Allergies

Dermatology Questionnaire PART “D”

If you do not know the answer to a question or do not understand the question please
leave the answer blank, DO NOT guess!
Download Dermatology Questionnaire in PDF format
Download PDF
 
Fax form to (604) 558-3379
or fill out online version below

A) GENERAL

*Indicates mandatory field
Owner Name*
Phone*
Email*
Clients Name*
Pets Name*
Breed*
Age*
Sex*
M F M/N F/S
Age or Date when you aquired pet
Where was your pet obtained
Breeder Pet store Private sale
Humane Society Stray Other  
 

B) SYMPTOMS

Describe the current skin problem(s)
Rash Hairloss Itching Smelly  
Other
Approximate date when problem FIRST started
     
Onset Sudden or Gradual
Are symptoms getting worse
Yes No
When did it start to get worse
Where on your pets body did the problem FIRST begin, check all that apply
Muzzle

Eyes

Ears

Neck

Back

Tail

Rump

Armpits

Front Legs

Back legs

Thighs

Front Paws

Back Paws

Chest

Abdomen

Groin

Other

   
What did the problem look like initially
Normal Skin, just “itch”  Pimples
Hair Loss Redness
Rash    Other
Has problem spread
Yes No  
If so when/where
Have the ears been involved ie: infected, waxy +/- itchy
Yes No
 
 

C) SYSTEMIC (General Health)

Any changes in weight
Yes No
If YES weight loss  or weight Gain
Any decrease in activity levels
Yes No
Any increase in drinking
Yes No
Any increase in urinating
Yes No
Any increase in appetite
Yes No
Any other medical/health conditions or illness
 
 

D) CONTAGION

Do you have any other pets in the household
Yes No
If YES please list
Do they have any skin problems
Yes No
If YES please describe
Do any people in the household have skin problems
Yes No
If YES please describe
Does your dog go to doggy daycare, groomers, dog parks etc
Yes No
If YES please describe how often
 

E) DRUG HISTORY (check all that apply)

Antihistamines (ie: Benadryl…)
When Did it help? 

When was it stopped?

Yes No
Cortisone (ie:prednisone, VanectylP)
Yes No
Cortisone Injections
Yes No
Atopica/Neoral (Cyclosporine)
Yes No
Antibiotics
Yes No
What kind of Antibiotics
Shampoo
Yes No
What kind Shampoo
Flea Control
Yes No
What kind Shampoo
 
Any fleas seen?
Yes No
Ear Meds  
which ones/when
Eye Meds  
which ones/when
Topical Meds  
which ones/when
Were there any adverse reactions to any of the above?
Yes No
If yes, what were the symptoms?
Vomiting Diarrhea Skin got worse
Severe Itching        
Other
 
 

F) FOOD HISTORY (check all that apply)

List pet foods, treats (cookies, biscuits, chews, snacks etc) and human food:
   
 
   
refresh
   
 
   
Submit
   

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