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How did you hear about Dermatology at Winslow Animal Hospital: _________________________ 1. Describe your pet’s skin problem (check al that apply): ( ) Scratching, chewing, licking, rubbing skin ( ) Other (describe) ________________________________ 2. Was itching the first sign of your pet’s skin disease that you noticed? ( ) Yes; ( ) No.
3. How long has your pet had this problem? ____________________days / weeks / months / years 4. Was the problem’s onset gradual ( ) or sudden ( )? 5. On a scale of 1-10 with 1 = occasional chewing or scratching and 10 = severe constant scratching that keeps you up at night, how would you rate your pet’s level of itchiness now? 6. Describe how the skin problem first appeared and how it changed over time: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 7. What areas of your pet are affected? (check al that apply) ( ) Ears; ( ) Face; ( ) Neck; ( ) Armpits; ( ) rump/tail area; ( ) Underside; ( ) Groin/inner thighs; ( ) Legs/paws; ( ) Anal/genital area; ( ) Other: ____________ 8. Has your pet always lived in this part of the country? ( ) Yes; ( ) No.
9. Has your pet ever traveled outside the U.S? ( ) Yes; ( ) No.
If yes, please list the dates of travel. _________________________________________________ 10. Is/are your pet’s problem(s) ( ) intermittent or ( ) continual? 11. Is there currently a relationship between your pet’s problem(s) and the season of the year?
( )Yes; ( )No. If yes, please check the season(s) when the problem is worse: ( )Spring; ( )Summer; ( ) Fal ; ( ) Winter. The problem begins in (month)_________________ 12. Do you have any other pets? ( ) Yes; ( ) No. Please list any other pets ______________________________________________________________________________ 13. Do your other pets have similar skin conditions? ( ) Yes; ( ) No; ( ) Does not apply.
If yes, what are the other pet’s problems? ________________________________________ ___________________________________________________________________________ 14. Has any person in your household had skin problems since your pet started having skin problems? ( ) Yes; ( ) No. If yes, describe: ________________________________________ _____________________________________________________________________________ 15. Have you noticed fleas on your pet recently? ( ) Yes; ( ) No.
16. What flea products do you currently use? __________________________________________ 17. Is your pet exposed to other animals or wildlife (dog parks, boarding, groomer, woods)? ( ) Yes; ( ) No. If yes, what kinds? _______________________________________________ 18. What treatment has your pet received for his/her skin problem? Check al that apply, list or circle ( ) Antibiotics (list) _____________________________________________________________ ( ) Antifungals e.g. ketoconazole, fluconazole ( ) Oral cortisone e.g. prednisone, Vetalog, dexamethasone ( ) Antihistamines e.g. Benadryl, atarax, chlorpheniramine ( ) Fatty acids/oils, fish oil capsules, Derm caps, vegetable oils ( ) Ear ointments or drops (list)______ _____________________________________________ ( ) Herbal or homeopathic remedies (list)___________________________________________ 19. Describe what response there was to this treatment. __________________________________ _____________________________________________________________________________ 20. Did medication help your pet’s problem(s)? ( ) Yes; ( ) No. If yes, which medication was the most effective? ________________________________________________________________ 21. What medications is your pet presently receiving and when was it last given? ______________________________________________________________________________ 22. Do you bathe your pet? ( ) Yes; ( ) No. If yes, how often? ____________________________ What is the name of the shampoo? ________________________________________________ 23. Do you clean your pet’s ears? ( ) Yes; ( ) No. If yes, how often? ________________________ What is the name of the ear cleaner? _______________________________________________ 24. Does your pet have any other previously diagnosed medical or surgical problems unrelated to the skin disorder? ( ) Yes; ( ) No. If yes, please describe: ______________________________ ______________________________________________________________________________ 25. List any medications your pet is receiving for this disorder: ______________________________ ______________________________________________________________________________ 26. Have you noticed any change in the health or behavior of your pet that coincided with the development of the skin condition? (e.g. changes in food or water intake, changes in urination or defecation, changes in activity level) ( ) Yes; ( ) No. If yes, please list: _____________________________________________________________________________ ______________________________________________________________________________ 27. Describe the current diet of your pet, including brand names and any table foods, treats, biscuits, vitamin supplements, or rawhide chews given: _________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 28. Has your pet ever been on a special food elimination diet? ( ) Yes; ( ) No. If yes, what commercial brand of food or home-cooked diet ingredients were used and for how long? ____________________________________________________________________________________________________________________________________________________________ 29. For dogs: is your pet currently on heartworm preventative (Heartgard, Interceptor, Sentinel, Revolution)? ( ) Yes; ( ) No. If yes, is it chewable? ( ) Yes; ( ) No. 30. For dogs: has your pet been blood tested for heartworm disease within the last 6 months? 31. For cats: has your cat tested negative fore Feline Leukemia (FeLV) and Feline Immunodeficiency Virus (FIV or feline AIDS virus)? ( ) Yes; ( ) No.

Source: http://winslowanimalhospital.com/files/2013/08/69791244-Dermatology-Questionnaire.pdf