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Dermatology Initial Consultation QuestionnaireIt is important to obtain a complete history in order to help in the diagnosis and management of allergies, ear disease, and skin disease. The detailed history you provide is very helpful and will provide the needed background for the clinicians and technicians best serve you and your companion animal. If you are unsure of how to respond to a particular question, we can help you. Our intention is to use the information you provide in this questionnaire to help during the examination and to help ensure the best possible treatment options for your companion animal.Date: ___________________________________________CLIENT INFORMATIONName: _______________________________________________________________________________E-mail Address: ________________________________________________________________________Do you prefer being contacted by e-mail? ?Yes ?No(Your e-mail will NOT be provided to any outside solicitors.)REFERRING VETERINARIANWere you referred by your veterinarian? ?Yes ?NoDid you request for records to be faxed? ?Yes ?NoHas your patient seen a veterinary dermatologist in the past? ?Yes ?NoIf Yes:Name of Hospital: ______________________________________________________________________Name of Veterinary Dermatologist: ________________________________________________________PATIENT INFORMATIONName: _______________________________________________________________________________Are you this pet’s owner? ?Yes ?No When did you adopt this pet? _____________________________Where did you adopt this pet? ____________________________________________________________PATIENT HISTORYPlease list any known underlying diseases/conditions: _________________________________________ __________________________________________________________________________________________________________________________________________________________________________What is the primary reason for today’s visit? _____________________________________________________________________________________Age when the problem was initially noticed:_________________________________________________How many days, years, or months have you noticed the problem? _______________________________Does there seem to be a seasonal influence? ?Yes ?NoIf yes, which season(s)? _________________________________________________________________Travel History / Recent Move: ____________________________________________________________Does your pet experience any of the following? ______________________________________________?Vomiting How Often?__________________?Tiredness/ How Often? ________________________?Diarrhea How Often?__________________ ?Hyperactive Behavior How Often?_______________?Coughing How Often? _________________?Lameness How Often? ________________________?Sneezing How Often? _________________Weight:?Maintained ?Increased ?Decreased Comment: ___________________________________________ _____________________________________________________________________________________Urination:?Maintained ?Increased ?Decreased Comment:___________________________________________ _____________________________________________________________________________________Drinking Behavior:?Maintained ?Increased ?Decreased Comment: ___________________________________________ _____________________________________________________________________________________Appetite:?Maintained ?Increased ?Decreased Comment: ________________________________________Please check any of the following clinical signs that pertain to your pet:?Itching ?Curving/Cracking/Breaking Nails?Licking/Chewing ?Loss of Nails?Flaky Skin (Dandruff) ?Hair Loss (Alopecia)?Red Skin ?Welts (Urtcaria/Wheals)?Thick Skin (Elephant Skin) ?Draining Lesions?Malodorous Ears ?Other: ____________________________________________?Bumps (Pustules or Papules) ?Other: ____________________________________________?Swollen Feet (Between Toes) ?Other: ____________________________________________Where do the lesions start (back, belly, groin, armpits, feet, ears, face)? _______________________________________________________________________________________________________________Onset of disease / lesions (gradual or sudden?) ______________________________________________ _____________________________________________________________________________________What did the lesions initially look like? _____________________________________________________ ___________________________________________________________________________________Where are the lesions the most severe (i.e., ears, feet, back, sides, etc.)? __________________________Do other animals or people in the house have lesions/itching? ?Yes ?NoIf yes, who? ____________________________________________________________________If your pet itches, please answer the following questions:On a scale of 1 – 10, how severe is the itching (1 slight – 10 severe)? _____________________________How frequent is the itching? ?Rare ?Sporadic ?ConstantWhen is the itching the worst? ?Always ?Daytime ?EveningIs there exposure to other animals? ?Yes ?No If yes, what kind? _______________________________What percentage of the time does your pet spend indoors or outdoors? ____% Indoors____ % OutdoorsDescribe what your pet sleeps on (pet’s bed, owner’s bed, feather bed, wool, outdoors): _____________________________________________________________________________________What is the current diet (i.e., canned, kibble, brand, etc.)? _____________________________________________________________________________________MEDICAL TREATMENTS / TESTSVaccinationsWhat vaccines (Rabies, DHLPP, FVRCP)? _________________________________________________________________________________________________________________________________________When were they last administered? _______________________________________________________Do you recall where on your pet the vaccinations were given (leg, shoulder, side)? _________________ DiagnosticsWhat diagnostic tests have already been performed? ______________________________________________________________________________________________________________________________Blood Tests (CBC, chemistry, thyroid panel, ACTH stimulation, etc.): ______________________________ _____________________________________________________________________________________Allergy Testing (serology, skin testing, diet testing): ___________________________________________ _____________________________________________________________________________________Skin or ear cytology: _________________________________________________________________________________________________________________________________________________________DietHas a special diet been tried? ?Yes ?No If yes, which diet(s)? _________________________________Does/Did the diet seem helpful? ?Yes ?NoWhat treats are provided (biscuits, rawhide/pig ears, hooves, bones, table food)? __________________ _____________________________________________________________________________________Do you brush your pet’s teeth? ?Yes ?No If yes, what flavor is the toothpaste? ___________________ Is your pet receiving heartworm prevention? ?Yes ?NoWhich brand? ?Heartgard? ?Iverhart? ?Interceptor? ?Sentinel? ?Revolution?-topical?Revolution?-topical ?Other: __________________________________________________________ If using an oral medication, is it flavored? ?Yes ?NoIs your pet receiving medication for arthritis/joint problems? ?Yes ?NoIf yes, which one? ?Chondroitin Sulfate - oral ?NSAIDS (Etogesic ?, Rimadyl?, Deramaxx?, Metacam?, other)Are these flavored? ?Yes ?No ______ If yes, list flavor(s): ____________________________________ Have treatments been tried for skin or ear disease/allergies? ?Yes ?No(Please indicate dose, route, duration, and if currently being used. Include treatments that are over-the-counter.)?Antihistamines:______________________________________________________________________ ?Corticosteroids: ______________________________________________________________________ ?Oral ?Injectable?Antibiotics/Anti-yeast: ________________________________________________________________ ?Essential Fatty Acids: _________________________________________________________________ ?Topical Therapy: _____________________________________________________________________ ?Other (i.e., allergy shots, natural supplements): ____________________________________________?Flea and/or Tick Prevention: ___________________________________________________________?Advantage? - topical ?K9 Advantix? - topical ?Revolution? - topical?Capstar? - oral ?Advantage-Multi? - topical ?Vectra??Comfortis?- oral ?Program? - oral ?Vectra? 3D?Frontline? - topical ?Program? - injectable ?Hartz??Frontline Plus? - topical ?Promeris?- topical ?Other: _________________________BATHING / SWIMMING HISTORYLast time bathed: ____________Frequency of bathing: ____________________________________ Product(s) used: __________________________________Bathing location (groomer, home, self-dog wash): ____________________________________________?Helpful ?No Change ?WorseSwimming: ?Yes ?No ?Ocean ?River ?Lake Frequency: ___________________________________Please provide any other information that you feel may be helpful (shampoo, ointments, creams, ear medications) (frequency of use, last date used/applied): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I give SCVSEC permission for unrestricted use of pictures of my pet taken at SCVSEC. ?Yes?NoSignature__________________________________________Date:______________________ ................
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