Dermatology Consult

Important Items to Note

• If you are unsure of your answer or do not understand the question, leave the answer blank. DO NOT guess

• The terms ITCHY refers to itching, scratching, licking, chewing, biting and rubbing

• Ears and paws are common areas for allergies, please consider these areas when questions are asked about ‘skin’

General Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Work Phone

Home Phone

Pets Name

Pets Breed

Birthday

(or approximate age)

Sex

Male
Female
Spayed/Neutered

Age or Date when you acquired your pet

Where did you acquire your pet?

(breeder, Humane Society, etc.)

Has your pet moved residence?

Yes
No

If yes, when

If yes, was it

Local
Another Province
International

If Yes

From To

Please list all species that live on the property

Does any animal or human have a history of skin problems

Yes
No

Has your pet been previously tested for allergies

Yes
No

If yes, please forward a copy of the results

Has your pet been seen by another Veterinarian

Yes
No

If yes, please have the medical record forwarded to us

Do you have your pet groomed

Yes
No

If yes, how frequently and what products are used

Do you travel off island with your pet

Yes
No

If yes, where

Does your pet go to day care

Yes
No

Do you board your pet

Yes
No

General Information

Provide a brief description of symptoms

Approximate date when the problem(s) first started

If the problem has been continuous for over one year, did it start of as seasonal

Yes
No
Unsure

How itchy is your pet on a scale of 1-10 (10 being the worst possible)

Are the symptoms getting worse

Yes
No

If yes, when did they start to get worse

Is there a time when your pet symptoms subside

Yes
No

If yes, when

Does your pet ‘ITCH’

Yes
No

If yes, check all that apply:

Was itching the first symptom that you noticed:

Yes
No

What did the problem look like initially

Normal skin, just itchy
Pimples
Hair loss
Rash
Redness

Has the problem spread

Yes
No

Have the ears been involved (itchy, infected, waxy)

Yes
No

Does your pet experience

(check all that apply)

Other

Has your pet received treatment for stomach or intestinal problems/upset

Yes
No

Has your pet ever been diagnosed with any other illnesses

Inside Environment

Percent of time spent

Indoors (%) Outdoors (%)

Type of flooring in your house

Carpets/Rugs (%) Tile/Wood (%)

Any of them wool?

Yes
No

Is the home smoke free

Yes
No

How is the home heated

Forced-air
Radiant
Heat Pump

When/where are the symptoms at their worst

Describe

Which room does your pet sleep in at night

Bedroom
Basement
Garage
Bathroom
Laundry Room
Family Room
Kitchen

Other

Where does your pet sleep at night

On bed
Under bed
Beside bed on floor
Couch/chair - Upholstered
Couch/chair - Vinyl/leather
Tile/wood floor
Carpet
Pet bed
Wool blanket

Which room does your pet spend most of its time in during the day

Bedroom
Basement
Garage
Bathroom
Laundry Room
Family Room
Kitchen

Other

Where does your pet spend most of its time during the day

On bed
Under bed
Beside bed on floor
Couch/chair - Upholstered
Couch/chair - Vinyl/leather
Tile/wood floor
Carpet
Pet bed
Wool blanket

Outside Environment

Does your pet spend time around

(check all the apply)

What types of trees are in your yard/neighborhood

While in your yard, does your pet spend time on

Grass
Deck
Cement/tiles

Drug History- please check all the apply

**Please bring along all medications that you are currently using or have used in the past**

Antihistamine (ie. Benadryl)

When?

Did it help?

Yes
No

When was it stopped

Cortisone (ie. Prednisone, Vanectyl)

When?

Did it help?

Yes
No

When was it stopped

Cortisone Injections

When?

Did it help?

Yes
No

When was it stopped

Atopica

When?

Did it help?

Yes
No

When was it stopped

Apoquel

When?

Did it help?

Yes
No

When was it stopped

Cytopoint Injections

When?

Did it help?

Yes
No

When was it stopped

Serum Allergy Injections

When?

Did it help?

Yes
No

When was it stopped

Antibiotics

What kind?

When?

Did it help?

Yes
No

When was it stopped

Shampoo

What kind?

When?

Did it help?

Yes
No

When was it stopped

Flea control

What kind?

When?

Did it help?

Yes
No

When was it stopped

Ear meds

What kind?

When?

Did it help?

Yes
No

When was it stopped

Topical meds

What kind?

When?

Did it help?

Yes
No

When was it stopped

Were there any adverse reactions to any of the above

Yes
No

If yes, please explain

Food History

List PET FOODS from the most current to the oldest:

Brand

How long was it fed for

List first 5 ingredients

Brand

How long was it fed for

List first 5 ingredients

Brand

How long was it fed for

List first 5 ingredients

Brand

How long was it fed for

List first 5 ingredients

If there are more than 5 diets, please list them on a separate sheet and bring to your appointment

List TREATS from most current to oldest (cookies, biscuits, chews, etc.)

Brand

How long was it fed for

List first 5 ingredients

Brand

How often is it given

List first 5 ingredients

Brand

How often is it given

List first 5 ingredients

Brand

How often is it given

List first 5 ingredients

Brand

How often is it given

List first 5 ingredients

If there are more than 5 treats, please list them on a separate sheet and bring to your appointment

List HUMAN FOOD that is given:

Food How often is it given

When you change diets/treats, do you notice your pet getting better

Yes
No

Explain

Do you feed any supplements

Yes
No

Is yes, what

Please do not hesitate to call us if your have any troubles with this form and we look forward to helping you and your pet at your appointment

Important Items to Note

General Information

General Information

Inside Environment

Outside Environment

Drug History- please check all the apply

Food History

Contact Us

Location Hours

Emergency Process

Cracking Nails
Sloughing Nails
Rash(es)
Red bumps
Pimples
Scabs
'Hot Spots’
Diarrhea
Constipation
Gas
Increased thirst
Foot problems
Interdigital cysts
Head Shaking
Ear scratching
Smelly ears
Vomiting
Poor appetite
Increased appetite
Increased Urination
Flaky, dry skin
Oily, greasy skin
Smelly skin
Lumps/bumps
Weight gain
Weight loss
Seizures
Lameness
Hair loss
Red skin
Thick skin
Red skin welts
Coughing
Sneezing
Runny eyes
Runny nose