Recheck Appointment Questionnaire Form
Patient Name Appointment
Reason for recheck appointment Annual Recheck Recommended by doctor Flare in symptoms related to ongoing issue New Problem If coming for a new problem, please specify How has your pet been doing since the last visit with us? Mild Improvement Moderate Improvement Excellent No change, still doing well No change, still doing poorly Mildly Worse Moderately Worse Severely Worse 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? Simparica Bravecto Nexgard Frontline or other topical Seresto Collar Revolution Comfortis or Trifexis Other My pet is not on flea and tick preventative 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? Daily to every other day Once a week Once to twice a month Less than once a month 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? Yes, A few days prior to giving the vaccine Yes, 24-48 hours after giving the vaccine No Not Sure
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?