Dermatology Questionaire

Patient Name:
Owner's Name:
Chief Complaint (please check all that apply):
Itching Hair Loss Sores
Ear Disease Chewing Other
When was the problem first noted?
MM/DD/YYYY
Where on the body did the problem begin?
Is the problem:
year round? seasonal? unknown?
If seasonal, in which season(s) is it worse?
Spring Summer Fall Winter
Where does your pet sleep or spend most of its time (i.e.Bedding,couch,etc.)?
If on a dog/cat bed, what is it filled with (i.e. Cedar, cotton, shavings, etc.)?
What kind of detergent do you wash the bedding with?
How frequently do you wash the bedding?
What do you feed your pet?(please check all that apply):
Canned Dry Table Food
Raw Meat
Other
What brand of food do you feed your pet?
What flavor is the primary food if known?:
Have you recently switched to a new brand or flavor of food?
Yes No
Does your pet itch (scratch, chew, lick, rub)?
Yes No
Is the itching:
Mild Moderate Severe Constant Periodic
Where does your pet itch? Check those areas which are itchy:
Face Abdomen Lower Back Ears
Front Feet/Legs Back Feet/Legs All over
What medications/supplements have been used?
Drug 1 Name

Drug 2 Name

Drug 3 Name
How Much

How Much

How Much
How Often

How Often

How Often
Did it Help

Did it Help

Did it Help
Do parents, littermates, other animals in the house or other animals in the area have a similar problem?
Yes No
Aside from the skin problem is your pet healthy?
Yes No
If no, (Please specify):