Subject
*
Your Name
*
First Name
Last Name
Pet Name:
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What is the primary complaint with the skin?
Are the ears involved?
If yes, explain.
When did the problem start?
What was skin like initially?
If other, explain.
Where did the problem start?
If other, explain.
Has the problem spread?
If yes, where?
Is your pet itchy?
(Itchy = scratch, rub, chew, lick, bite, etc)
If itchy, was it from onset of the problem or is it a new occurrence?
If your pet is itchy, please grade the degree of irritation on a scale of 1 (minimal) to 10 (severe):
Is the skin problem worse or more severe at a certain time of the year, or is it the same throughout the year?
If worse at a certain time of year, what time of year is it worse?
Do you have any other pets?
If yes, please list.
Do your other pets have any skin problems?
If yes, please describe.
Do any people in your house have a skin condition or problem?
What do you feed your pet?
What type of supplements/vitamins do you give your pet?
What type of snacks or treats does your pet get (include human food)?
What medication is your pet currently on?
Has your pet ever had a reaction to any medication?
Is your pet on flea control?
If yes, what type?
Is your pet on heartworm prevention?
If yes, what type?
How often do you bathe your pet?
What shampoo do you use?
What percentage of a day does your pet spend indoors?
Outdoors?
Please describe the outdoor environment.
Does your pet have any other illnesses?
If yes, which ones?
Does your pet do any of the following excessively:
How many bowel movements does your pet have per day?
