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Re-check 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 Re-check 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* Exam Date* Clients Name* Pets Name* Breed* Age* Sex M F M/N F/S     B) SYMPTOMS Describe the current skin problem Rash Hairloss Itching Other   If your pet is itchy (chewing, licking, biting, scratching or rubbing) answer the following a) On a scale of 1-10 (10 being worst) how itchy is your pet Select 1 2 3 4 5 6 7 8 9 10 b) Where is your pet itching (list from most to least) Are there other pets that have contact with patient who show similar skin problems? Yes No If YES describe What has happened with your pets condition since the last exam with Dr.Charach Is your pet on an allergy vaccines? Yes No   If so how much & how often What medications are you currently or have been giving since the last visit with Dr.Charach, Please include all oral, topical or injectables used Medication Did it help? When was it last given Yes No Yes No Yes No Yes No Yes No Yes No Has your address, phone number or primary veterinarian changed? Yes No New information   Please wait...

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