Dermatology Follow-Up Questionnaire

IMPORTANT INFORMATION:

If you do not know the answer to a question or do not understand the question, leave it blank. Please do not guess.

    GENERAL INFORMATION

    1.) What is the current skin / ear problem?

    OdorRednessItchingHead ShakingDandruff / Dry SkinOily / Greasy SkinDarkening of SkinHair Loss

    2.) If your pet is itchy (licking, chewing, biting, scratching, rubbing) please answer the following:

    How itchy is your pet on the itch scale?

    Canine Itch Scale

    Feline Itch Scale

    (Click your pet’s species for the appropriate scale to make an assessment of your pet’s itch score)

    Which areas is your pet itching the most?

    3.) Are there any other in-contact pets that exhibit similar symptoms?

    YesNo

    4.) Is your pet on allergy vaccine (allergy specific immunotherapy)?

    YesNo

    If yes, which of the following methods is being used for immunotherapy:

    Oral DropsInjectable Therapy

    5.) Which medications have been used since your last dermatology visit? Please include all oral, topical, injectable and shampoo therapy administered:

    6.) Has any of your contact information (contact email, phone number, address, etc) or family veterinarian changed since your last visit with us?

    If yes, please provide the current information:

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