Animal Dermatology Clinic of BC

Call Now! 1 604-558-3376

Follow Us on Follow Us on Twitter
Become a Fan Facebook
Certified Specialist in Skin, Ears, Hair, Nails and Allergies

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
Download PDF
 
Fax form to (604) 558-3379
or fill out online version below

A) GENERAL

*Indicates mandatory field
Owner Name*
Phone*
Email*
Exam Date* Click Here to Pick up the 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
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
 
refresh
 

Back