Dermatology history for pets with skin or ear problems. Please complete all applicable questions.

Phone

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Patient information

Date(Required)

Your name(Required)

Patient / pet name(Required)

Dermatology history — questions 1–22

1. What skin or ear problem are you bringing your pet in for?(Required)

2a. How long has the problem been present?(Required)

2b. How old was your pet when the problem first started?(Required)

3. When the problem started, did it come on suddenly or gradually over a period of time?(Required)

Suddenly

Gradually

4. What did the skin or ear problem look like initially?(Required)

5. How has it changed or spread?(Required)

6. The problem has been (check one):(Required)

Continual, even with medication

Continual but better with medication

Intermittent or sporadic

7. Is the problem worse during certain times of the year? If so, when?

8. Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease?(Required)

1 = occasional scratch (normal); 10 = constant, severe scratching.

9. Using the same 1 to 10 scale, how itchy has your pet been over the past month?(Required)

1 = occasional scratch (normal); 10 = constant, severe scratching.

10. Is your pet receiving any treatment now? If yes, what kind?

11. When did your pet last receive any medication, and what medication was it?

12. What do you feed your pet now?

13. Have any different diets been tried as treatment? If so, list the brand name and for how long you fed it.

14. How often do you usually bathe your pet? With what?

15. When was the last time you saw a flea on your pet or another pet in the household?

16. Do you routinely use flea or tick preventive products on your pet (list type)?

17a. How old was your pet when you obtained him/her?

17b. Where did you get your pet?

18. What other pets are in the household?

19a. Do any of the other pets have skin problems?

19b. Do any people in the household have skin problems?

20a. What percentage of the day and night does your pet spend indoors?

Please enter a number from 0 to 100.

Enter a percentage from 0 to 100 (without the % symbol).

20b. What percentage of the day and night does your pet spend outdoors?

Please enter a number from 0 to 100.

Enter a percentage from 0 to 100 (without the % symbol).

21. Other than skin disease, does your pet have any diagnosed medical problems?

22. Please list any other clinical signs or anything else you suspect might be contributing to your pet’s skin or ear disease.

23. Clinical signs and severity

For each clinical sign, select how severe it has been over the entire course of your pet’s skin or ear problem.

23.01. Scratching/licking/biting at self(Required)

Never occurs or none

Occurs rarely or slight