Date:
Skin Evaluation Form
Patient: ________________________ Owner: _________________________ Date: ________________________
Yes No ?
1. Does the skin condition seem better or worse during any particular season?
If so, which one? ____________________________
2. Do other pets in your household have skin problems?
3. Do any relatives of your pet have skin problems?
4. Do any people in your household have skin problems?
5. Do you use any flea control products? If so which ones have you tried? __________
___________________________________________________________________
6. Do you bathe your pet? If so how often and with what? _______________________ ____________________________________________________________________
7. Is there any condition or environment that makes the skin problem noticeably worse?
(i.e., being outside, walking on grass, the day you vacuum, etc.…) ______________
____________________________________________________________________
8. Has your pet experienced vomiting or disagreement with certain foods?
If so, which one(s)? ___________________________________________________
9. Have you tried changing your dog’s diet? If so list what it has ever been changed to.
___________________________________________________________________
10. Has your pet ever seemed to be ill from his skin disease (depressed, fever, not eating,
etc.?)
11. Does your dog eat dry food? If so, what brand and how long have they been on it?
____________________________________________________________________
12. Does your dog eat canned food? If so, what brand and how long have they been on it?
____________________________________________________________________
13. Does your dog get treats? If so, what kind and how often? _____________________
14. Does your dog get people/table food? If so, what kinds of food and how often?
____________________________________________________________________
15. How many times a day does your pet have a bowel movement? _________________
The consistency of each stool is: CIRCLE ONE Firm and formed Soft and formed Loose Diarrhea
Severity Evaluation: On a scale of 0 to 10 rank the severity of your pet’s symptoms.
No Symptoms Severe
0 1 2 3 4 5 6 7 8 9 10
Please check any of the following that are now present relating to your pet’s skin:
Scratching [pic] Greasy skin or coat [pic] Oozing sores
Biting [pic] Scaly skin (dandruff) [pic] Body odor
Licking [pic] Crusty skin [pic] Hair loss
Rubbing Face on floor/furniture [pic] Redness [pic] Darkening of skin
Change in thirst [pic] Pimples [pic] Lightening of skin
Shaking head [pic] “Bumps” on skin [pic] Thickening of skin
Dry skin or coat [pic] Drags “Butt” on floor [pic] Fleas
Please circle your dog’s problem area(s)
[pic]
1. How long has your pet had a skin problem? Years________ Months________ Days________
2. Age of pet when obtained: Years________ Months________ Days________
3. Age when skin problem started: Years________ Months________ Days________
4. Where on the body did the problem start? ___________________________________________________________
5. What did it look like initially? ____________________________________________________________________
6. If your pet is scratching, did you notice the itching or the skin lesions first? [pic] Itching [pic] Skin Lesions
7. How has it spread or changed? ____________________________________________________________________
8. On the list of medications below, check which types of medication your pet has been given, and, if so, how much relief they produced:
|Treatment or medication |Yes |No |Not Sure |Did not help |Helped some |Helped a lot |
|Cortisone pills or shots (steroids, Temaril, prednisone, Vetalog, anti-itch pills) | | | | | | |
|Antibiotics alone (with no other medication given at the same time) | | | | | | |
|Antihistamine (Benadryl, Zyrtec, etc.) | | | | | | |
|Antifungal medications (ketoconazole, etc.) | | | | | | |
|Cyclosporine (Atopica) | | | | | | |
|Apoquel | | | | | | |
|Allergy shots or drops | | | | | | |
9. Any other thoughts you have relating to the skin disease (e.g., what do you think may be the cause of the skin problems?) ___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
-----------------------
If given, how much did it help?
Was it ever given?
Treatment or medication
................
................
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