Recheck Appointment Questionnaire Form
Patient Name Reason for recheck appointment If coming for a new problem, please specify How has your pet been doing since the last visit with us? Is your pet itchy? If so, please rank his/her itch on a scale of 1-10 (10=itchiest) Are there any current ear problems? If yes, please specify. Are you applying any ear medications? If so, please list what medications you are applying. What flea and tick preventative are you using on this pet? When was the last dose of flea and tick preventative given and how often do you administer it? Are you currently using any heartworm preventative on this pet? If so, please list what product you are using. What food are you currently feeding? Please include any treats your pet receives. How often are you bathing your pet? What shampoo do you use to bathe your pet? Please list all medications that your pet is on below: Please list any other known health issues not related to the dermatologic disease: Do you need any refills? If so, please list which medications you would like us to refill. If your pet is on Injectable Allergy Vaccine, please answer the following questions:
How much of the vaccine are you giving and how frequently are you giving the injections? Do you notice an increase in itch associated with the injection? If your pet is receiving Cytopoint injections, please answer the following questions:
How often does your pet receive Cytopoint injections? When was your pet's last Cytopoint injection?
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