Animal Dermatology Clinic of BC

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

Equine Dermatology Questionnaire

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 Equine Dermatology Questionnaire in PDF format
Download PDF
 
Fax form to (604) 558-3379
or fill out online version below

A) GENERAL

*Indicates mandatory field
Name*
Email*
Client Name*
Horse Name*
Breed*
Age*
Sex*
M F G    
Age when you aquired Horse
What is the horse’s use
 
 

B) SYMPTOMS

Describe the current skin problem(s)
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 the body did the problem FIRST begin
What did the problem look like initially
Has problem changed or spread
Yes No  
If so when/where
Is the problem
continual or intermittent
If seasonal what seasons is the disease present
Does the Horse itch
Yes No  
If yes where
Do any horses in contact with the affected horse have skin problems
If so, are they similar or different from this horse’s problem
Do any people in contact with the horse have skin problems
Yes No  
Do you use insect control
Yes No  
If yes, describe
Do any relatives of this horse have skin problems
Yes No  
If yes, describe
 
 

C) DRUG HISTORY - Veterinary or “home” remedies (check all that apply)

Antihistamines
When Did it help? 

When was it stopped?

Yes No
Cortisone (oral)
Yes No
Cortisone Injections
Yes No
Antibiotics
Yes No
What kind of Antibiotics
Shampoo
Yes No
What kind of Shampoo
Topical Meds
Yes No
which ones/when
Were there any adverse reactions to any of the above?
Yes No
If yes, what were the symptoms?
List any other treatments
What is your deworming schedule
Did the horse receive Ivermectin
Yes No
List any other medical problems or drugs that the horse received
 
 

D) ENVIRONMENT

Percent of time spent…  
Indoors %
Outdoors %
Does this horse travel
If yes, where and when
 
 

E) FOOD HISTORY

What is this horse fed (List foods with ingredients, treats and human foods)
What additives do you use
 
 

F) OTHER

List any additional information you feel is relevant to the skin disease
 
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