Pet dermatology questionnaire

Pet Dermatology questionnaire

Please print and fill out prior to coming in for your skin consultation

 

Pet’s name:

  1. What is the main skin problem?
  2. At what age was this condition first noticed?
  3. Have there ever been any previous ear or skin problems?

Symptoms

  1. Have any of the following been observed:

Sores

 

Odour

 

Diarrhoea

 

Depression

 

Scabs

 

Hives

 

Tiredness

 

Increased thirst

 

Dandruff

 

Heat

 

Weight loss

 

Increased appetite

 

Hair loss

 

Redness

 

Weight gain

 

 

Please omit questions 5, 6 and 7 if you did NOT tick ear infections above

 

  1. Ear infections

Is one ear affected or both? Left     Right

Is one ear worse than the other? Left       Right

Approximately how many times has your pet been treated for ear infections?

 

  1. Have any of the following been observed?

Ear discharge

 

Head shaking

 

Scratching the ear

 

Rubbing the ear

 

Head tilt

 

haematoma

 

Loss of balance

 

Eye movement

 

 

  1. Do you know of any relatives of this pet that have ear problems              Yes         No

 

  1. Does your pet

Rub at the face

 

Head shake

 

Scratch/rub at ears

 

Bite the limbs

 

Scratch at the flanks

 

Bite the stomach area

 

Roll on the back

 

Bite at the tail area/anus

 

Rub against tree/post

 

Eye discharge

 

Sneeze

 

Wheeze or cough

 

Other:

 

  1. Do the symptoms vary?

If the dermatitis or ear problems has been present for some time, are the symptoms worse in:

Spring o                         Summer o                        Autumn o                         Winter o

Are there symptoms present all year round?                      Yes  No

If yes, would there be a time of no symptoms?                 Yes  No

What, if anything, causes a worsening of symptoms?

 

What helps?

 

  1. Home details

Are there any other in-contact animals?                                                Yes  No

If so, how many?             Horses                  Dogs                      Cats                       Rodents               Birds

Other

Do you know of any relatives of this pet that have skin problems?            Yes  No

Does any in-contact human have skin problems?                                              Yes  No

Please estimate how much time your pet spends             Indoors _____% Outdoors _____%

Does your pet swim?     Yes  No   If so, how often?

And where? 

Where does this pet sleep: what room?

What type of bedding?               

What type of flooring do you have in your house?

Where do you walk your pet, and how often?

  1. Bathing

Does bathing                     Help o                                                Worsen   o                         Make no difference o

What type of shampoo are you using?

How often do you bath your pet?            Weekly o          Monthly o        Rarely   o          Other o

  1. Insects and fleas

When was the last time a flea was seen on this pet?

When was the last time a flea was seen on your other pets?

What is the current flea treatment on this pet?

How frequently do you use this product?

Is flea treatment used on other pets?

Do you see other insects in your environment?

Mosquitos o                   Flieso                 Ants o                                Cockroaches o                  Moths o

  1. Medication

Do you know what previous medications have been used?

Ear drops o      Tablets o                           Injections            o          Ointments, lotions etc o

Rinses  o

What were the names and the dose of any medications and the last date given? (please list)

 

 

 

Is your dog on heartworm prevention? Yes No                  If yes, what type?

  1. Diet

What do you normally feed your pet?    Cans o  Dry o              Table scraps                     Meat o

If meat – which types?                

Any supplements? (e.g. vitamins, minerals, fatty acids, glucosamine etc)

What do you give for snacks and treats?

Have you ever fed a special diet?  Yes  No     If yes, what diet?

  1. General Health

Have there been any episodes of:

Vomiting

 

Diarrhoea

 

Mucous stools

 

Lethargy

 

Increased water intake

 

Increased appetite

 

Weight gain

 

Weight loss

 

Weakness

 

 

 

 

 

 

 

Does your pet have any other illness? If so, please specify illness and prescribed medications:

 

 

 

  1. What do you think could be the cause of the skin problem?