Home » Pre-Consult Form: Dermatology

Pre-Consult Form: Dermatology

Client Information

Date(Required)

Month

Day

Year

Client Name(Required)

First Last

Pet's Name(Required)

History

Please tell us your primary concerns:(Required)

When did the problem first appear?(Required)

Is your pet itchy?(Required)

Yes

On a scale of 1 to 10, how itchy is your pet?(Required)

1 - very mild : 10 - severe/constant

Please enter a number from 1 to 10.

Where is your pet itching?(Required)

Please select all that apply

Head/face

Ears

Neck

Chest

Groin

Tailbase

Legs

Paws

Is your pet's itching:(Required)

Year-round

Seasonal

When your pet's itching started was it:(Required)

Year-round

Seasonal

Please provide any additional details regarding your pets itchiness:

Is your pet displaying any of the following? Please select all that apply: :

Biting

Scratching

Licking

Chewing

Gnawing

Rubbing

Has your pet had any ear disease?(Required)

Yes

If yes, please list current or in the past and approximate time frame.

Please list any other health problems your pet may have or is being treated for:(Required)

Diet

Please tell us about your pet's current diet:

Commercial Food (name):(Required)

Treats (name):(Required)

Table Food:(Required)

Flavored Medications:(Required)

Are there any known reactions to foods, treats, or diet in the past?

Yes

If yes, please describe:

Are there any previous special diets used for skin disease?

Yes

If yes, please describe:

Medications

Please list all CURRENT medications your pet is taking and if it is helpful.(Required)

Please include all steroids, antibiotics, antifungals, and ear medications. Use the plus sign to add another medication.

Medication

Helpful: Yes/No

Please list all PREVIOUS medications your pet has taken and if it was helpful.(Required)

Please include all steroids, antibiotics, antifungals, and ear medications. Use the plus sign to add another medication.

Medication

Helpful: Yes/No

Please list all other medications that your pet has taken for non-dermatologic related illnesses.(Required)

Use the plus sign to add another medication.

Please tell us of any known drug reactions or allergies, topical or systemic:(Required)

Please list any shampoos, lotions, sprays, and/or wipes and how often you use them:(Required)

Product

Frequency

Environment

Which flea control product to you use?(Required)

How often do you apply the flea control product?(Required)

Do you give it:(Required)

Year-round

Seasonally

N/A

Have you ever seen fleas on your pet?(Required)

Yes

Have you ever seen fleas on other pets in your home?(Required)

Yes

N/A

Which heartworm prevention do you use?(Required)

How often to you give heartworm prevention?(Required)

Do you give it:(Required)

Year-round

Seasonally

N/A

Please tell us the percentage of time your pet spends indoors and outdoors:(Required)

Does your pet go to doggy daycare, get groomed, or boarded regularly?(Required)

Are there any other pets in the household?

Yes

If yes, do any of the other pets have skin disease or are itchy?

Do any humans that your pets have regular contact with have skin disease?(Required)

Yes

If yes, please describe:

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