Dermatology Questionnaire
Date:
Patient Name:
Client Name:
Thank you for allowing us to be a part of your pet’s healthcare. Our hospital is a fullservice veterinary hospital with a focus on preventative care in addition to general
medicine and surgery. To help us get to know your pet’s health, facilitate your
experience, avoid appointment delays or rescheduling, please complete this form
within 48 hours by email (or fax) of your first appointment (including newly adopted
patients with minimal histories to pets with extensive medical histories). Please fill
out one form for each pet to the contact information below.
Has your pet been to a veterinarian before?
☐ Yes
☐ No (skip to question 2)
If yes, please list the most recent 3 veterinary clinics (at least name, city/state – ideally phone number or email address if
feasible). If the pet was previously listed under another name or individual on the medical chart please note that also.
E.g. Two Rivers Veterinary Hospital, West Fargo, ND 701.356.5588 info@tworiversveterinaryhospital.com
1.
2.
3.
Skin (and itching) conditions can be caused by many conditions. To help streamline your visit with appropriate
testing/treatment it is important for us to have the answers to the following questions prior to your appointment:
When did most recent itch/skin symptoms start?
Has similar symptoms been seen in the past?
If so, how long did the itch last?
Are the skin symptoms/itching noted year-round or just during certain seasons?
Itch level:
Current ___ out of 10 (10 = most severe)
In past ___ out of 10
Location of itch on body (most affected areas)?
Is monthly flea prevention used on ALL animals in house?
Date of last application?
Has diets/treats changed?
If so, when:
Current diet (specific brand and variety):
Current treats:
All past diet/treats:
Is the pet current shampood?
At home or at a grooming facility (typically)?
Prescription or over-the-counter?
Brand?
How often is shampoo therapy?
Date of last shampoo therapy?
Other topicals/surface medications used on the skin?
If so, type and frequency of application:
What (if anything) has seemed to help in the past?
On omega fatty acid?
If yes, brand and dose?
How often given?
When started?
Using antihistamines (e.g. Benadryl/diphenhydramine, etc)?
If yes, dose and frequency?
Diagnostics performed in past (if known)?
Email: lisa@tworiversveterinaryhospital.com
Phone: 701.356.5588
Fax: 701.356.5589
Dermatology Questionnaire
Date:
Patient Name:
Client Name:
skin scrapings for mites:
cellophane tape preps or other microscopic cytology?
skin culture:
fungal culture:
prescription food trial:
brand:
how long was it fed?
were any treats fed at same time?
History of ear infections?
how often?
ears routinely cleaned?
if yes, brand of cleaner
if yes, frequency of cleaning
have any ear infections been rechecked to confirm resolution of infection?
Does any of the humans or other pets have skin lesions or itching?
Main concern today?
2. Do you consider your pet overall healthy at home? If unsure, please list the top concern(s) you may like us to further
address during the visit. ☐ No concerns at this time (skip to question 3)
☐Yes (please specify below)
1st concern:
2nd:
3rd:
4th:
5th:
What medications is your pet currently taking? *Please bring in with you to your appointment
Vitamins/Minerals
Flea/Tick
(e.g. omega fatty acid, SynoviG4s
glucosamine/chondroitin sulfate, etc)
(e.g. Parastar Plus, Frontline
Plus, K9 Advantix)
Monthly parasite
preventative
(e.g. Sentinel, Heartgard
Plus, Revolution)
Other prescriptions –
include frequency/dose
(e.g. topical shampoos,
Rimadyl, etc)
Any other questions/comments that would benefit our team:
Sincerely,
Tracie Hoggarth, DVM and Teri-Lee James, DVM MPH
Email: lisa@tworiversveterinaryhospital.com
Phone: 701.356.5588
Fax: 701.356.5589