|
Pet Name
|
|
Date of Appointment
|
What is your pet's main problem? Check all that apply |
Itching (includes scratching, chewing, licking, rubbing, and biting)
|
Ear problems
|
Skin rash
|
Skin infections
|
Hair loss
|
Dry skin, scaling, dandruff
|
Other, please describe
|
What age was your pet when the problems began?
|
Rate itch level on a scale of 1 to 10 (1 = minimal, 10 = obsessive) :
|
Please check all of your pet's affected areas |
Face
|
Ears
|
Neck
|
Tail
|
Groin
|
Arm pits
|
Legs
|
Feet/paws
|
Abdomen
|
Back
|
Sides
|
Nails
|
Nose
|
In which location did the problem begin?
|
Is the problem seasonal or year round?
seasonal
year round
|
If seasonal, in which season does the problem occur?
winter
spring
summer
fall
|
If year round, do the signs worsen during a particular season?
winter
spring
summer
fall
no
|
Do you have any other pets? Check all that apply |
Dogs
|
Cats
|
Birds
|
Other (fish, horses, reptiles, hamster, etc)
|
Do any of the other pets have skin problems? If so, please describe
|
Do any people in the home have skin lesions? If yes, please describe
|
Diet Questions |
What is your pet's current diet, include treats
|
Has your pet ever been on a prescription diet to rule out food allergies?
yes
no
|
Environmental Questions |
What percentage of time does your pet spend indoors vs. outdoors?
|
What is the primary indoor flooring surface? :
|
Do you have wool carpeting?
yes
no
|
Does anyone in the household smoke?
yes
no
|
Does your pet have any other signs of illness?
yes
no
|
If so, describe
|
What is your pet's flea/tick prevention? How often is it applied?
|
Treatment: Has your pet received the following medications? |
Antihistamines (Benadryl, Hydroxyzine, Zyrtec, other)? Did they help?
|
Steroids (Prednisone, Temaril P, Steroid/cortisone shots)? Did they help?
|
Antibiotics (Cephalexin, Simplicef, Clavamox, Baytril, Zeniquin)? Did they help?
|
Shampoos/conditioners? Did they help?
|
Allergy shots? Did they help?
|
Atopica (cyclosporine)? Did it help?
|
Please list the current medications that your pet is receiving
|
Processing ....