Pittsburgh Veterinary Dermatology

807 Camp Horne Rd
Pittsburgh, PA 15237

(412)366-3400

www.pittvetderm.com

Please schedule a recheck appointment before filling out this form.  We are offering this form online as a way of expediting your check-in process.  If you are having difficulty with the form not submitting and you are using a smart phone or a tablet, please try to fill it out on a computer.

Recheck Questionnaire

Recheck Appointment Questionnaire Form
Client Name
First Name
Last Name
Spouse/Other Owner
First Name
Last Name
Patient Name

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?


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