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?


  1. Have any of the following been observed:















Increased thirst






Weight loss


Increased appetite


Hair loss




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




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




Wheeze or cough




  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


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:





Mucous stools




Increased water intake


Increased appetite


Weight gain


Weight loss










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?