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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
Fax form to (604) 279-2040
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:

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