E-Mail Address : Date and time of your scheduled appointment
Please tell us your preferred mode of communication. Text messages will be limited to appointment reminders only. Please note the best way to reach you during the day. Please list all veterinary offices visited in the past 3 years. Please include phone number if available. How did you hear about us? Does your pet see any other service at PVSEC? If yes, please specify.
Patient Name Species Canine Feline Other Breed Sex Male Female Neutered Male Spayed Female Birth Date (or estimate)
Color/Markings Are you this pet's owner? Yes No How old was your pet when you got him/her? Where did you obtain this pet? Breeder Shelter Pet Shop Other Has this pet ever lived/visited outside your current geographical area? Yes No Unknown What percentage of the time does your pet spend indoors or outdoors? % Indoors % Outdoors Does your pet go to a boarding kennel Yes No If yes, how often? Does your pet go to the groomers? Yes No If yes, how often? Please briefly list any known health problems OTHER than skin/ear disease: Please list any medications given to this pet for problems OTHER than skin disease:
What dermatological problem are you bringing your pet in for? How long has the problem been present? How old was your pet when the problem first started? When the problem first started, did it come on: Suddenly Gradually over a period of time Does your pet have any of the following? Cough Runny Eyes Diarrhea Constipation Loss of Appetite Excessive Urination Sneezing Ear Infections Vomiting Excessive Drinking Limping Weight Loss Weight Gain If you checked any of the above, please list frequency and description: Which would you say best describes the progression of your pet's skin problem? I first noticed a skin rash or hair loss which does not seem to bother my pet. I first noticed a skin rash or hair loss and afterwards some itching developed (chewing, biting, scratching, rubbing, or licking) I first noticed some itching (chewing, biting, scratching, rubbing, or licking) before any hair loss/rash
If your pet is itchy (chewing, biting, scratching, rubbing, or licking), please answer the following questions:
Does your pet scratch, rub, lick, chew, or bite any of the following areas? Nose/Muzzle Eyes Back Paws Front Paws Chest Back Front Legs Back Legs Tail Abdomen Rump Ears Armpits Inner Thighs and Legs Other Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease? On a scale of 1-10, how severe is the itching? (1=slight, 10=severe/constant, keeps you awake at night, stops normal activity to scratch) How itchy has your pet been over the last month? On a scale of 1-10, how severe is the itching? (1=slight, 10=severe/constant, keeps you awake at night, stops normal activities to scratch) How frequent it the itching? : Rare Sporadic Constant Is the problem year-round? Yes, it has always been year-round Yes, but it used to be seasonal (only part of the year) No Unknown If seasonal, which time of year is the problem present or more severe? Spring Summer Fall Winter
Please list ALL medications your pet is currently taking for their skin and ear disease (Include supplements and treatments that are over-the-counter). Please bring all the medications, supplements or topical treatments that you use to your appointment if possible. Please list Name of medication, dose of medication (if known), how long your pet has been receiving the treatment, are they currently being used, when was the last dose given. Did any of the medications help the problem? If so, which ones? Is your pet receiving fatty acids? Please list brand if known. Please list any topical therapies such as ear cleaners and/or medications, topical sprays, lotions, wipes, ointments/creams: Is your pet on allergy vaccine? Yes No
How many bowel movements does your pet have per day? Has your pet been treated for stomach or intestinal problems? If yes, please explain. What brand and flavor of diet do you feed your pet currently? What treats are provided (biscuits, rawhide/pig ears, hooves, bones, table food)? Do you brush your pet's teeth? If yes, what flavor is the toothpaste? If using an oral medication, is it flavored? Yes No Don't Know Is your pet receiving medication for arthritis/joint problems? Yes No Don't Know If yes, which one(s)? Chondroitin Sulfate Glucosamine Etogesic Rimadyl Deramaxx Metacam Other Are the supplements/medication that you are using flavored? If yes, list flavor(s) if known. Have you ever done a strict food trial (nothing besides the prescription diet and approved treats were fed during the food trial) using only a prescription diet prescribed by your veterinarian? If yes, what food was fed?
How often do you usually bathe your pet? When was the last time you bathed your pet? Can you bathe your pet? Yes No Where do you bathe your pet? At home At a self service dog wash Groomer What shampoo do you use? Do you have a medicated shampoo prescribed to you by your veterinarian? If so, please list which ones and bring them to your appointment. Do you think bathing your pet is helpful? Yes No
Do you routinely use flea control? Yes No If yes, which one is used? Advantage - topical Frontline/Frontline Plus - topical K9 Advantix - topical Revolution - topical Hartz/Biospot/Other OTC topical spot-on Parastar/Parastar Plus Comfortis Trifexis Bravecto Nexgard Simparica Credelio Capstar Seresto Collar Other How often is flea/tick control applied/given to this pet? How often is it applied to other pets in the household? When was the last time you saw a flea on your pet? When was the last time you saw a flea on other pets or on in-contact animals?
Do you own any other pets? If yes, what kind? Are the other pets: Indoors Outdoors Both Is there exposure to other animals outside your household? If yes, what kind? Do other animals or people in the house have lesions/itching? If yes, who? Do you know if any litter mates or the parents of this pet have similar skin problems? Do you or any family member work in the healthcare field? If yes, what is the occupation?
Is your pet up to date on vaccinations? Yes No Don't know
Is your pet receiving heartworm prevention? : Yes No Don't Know If yes, which brand? Heartgard Interceptor Sentinel Sentinel Spectrum Revolution Trifexis Other Has your pet been tested for heartworm disease in the past 12 months? Yes No Don't know
Has your pet tested negative for Feline Leukemia Virus (FeLV) and Feline Immunodeficiency Virus(FIV or Feline AIDS)? Yes No Don't Know When was the last test done? Are there any other symptoms that your pet has that have not been described above, or is there anything else you think might be contributing to your pet's skin or ear disease?