Dermatology Evaluation Form (please copy all pages, fill out, and bring with you to the office.)|
Date ________________ Pet owner name______________________
Name of Pet_________________ Age ________ Breed___________________
Please check any of these that describe your dog and circle problem areas on the drawing.
____ hair loss ____ foul odor ____ inflammaton or redness
____ itching/scratching ____ otitis (ear infections)
____ licking/chewing ____ skin lesions (sores)
____ changes in the skin (reddish brown stains, discolorations,
and/or areas that are thick and leathery.
Where 0=no symptoms and 10=severe symptoms, rate the following on a
scale of 0-10.
____ severity of overall condiiton _____ severity of skin lesions
____ severity of licking/chewing/scratching
Onset and Seasonality Evaluation.
1. Is this the first time your pet has experienced these symptoms? ___yes ___no
a. At what age did the symptoms first occur?
___<1 yr. ___ 1-3 yrs ___ 4-7 yrs ___ 7+ yrs.
b. Has it occured around the same time of year each time? ___ yes ___no
c. When is the approximate time of year that it occurs? ____________________
2. How long have the current symptoms been going on? _____________________
3. Did the itch start gradually and over time get worse? ___ yes ___ no
4. Did the itch come on suddenly without warning? ___ yes ___ no
5. Was there a "rash" first or did the itching occur first or at the same time?
___ rash first ___ itch first ___ both at same time
1. Is your pet on flea/heartworm preventive?
___ yes ( product(s)_____________________________)
2. What months do you administer the flea/heartworm preventive?
flea _______________ through __________________
heartworm ______________thorugh ________________
3. When was the last dose of the these medicaitons?
1. This pet lives inside _____ outside _____ both _____
If outside, please describe the environment. _______________________
2. Are there other pets in your household? ___ yes ___no
If yes, do they have similar symptoms? ___ yes ___ no
If these pets are cats, do they go outside? ___ yes ____ no
3. Do you board your pet(s), take him or her to obedience classes, training,
or groomers? ____ yes ___ no
If yes, when was the last time you took your pet? ___________________
4. Have you taken your pet on a trip or to another location? ___ yes ___ no
If yes, when was the last trip and where was the destination?
5. Have you recently moved? ___ yes ___ no
6. Have you been to a new dog partk or walking trail? ___ yes ___ no
7. Have you recently used any new shampoo or topical skin treatments recently?
___ yes ___ no
8. Are any humans in the household exhibiting any skin problems?
___ yes ___ no
1. My pet eats ___________________________________________________
2. Do you feed the same food all the time or provide a variety"
____ always the same ___ variety
3. Have you changed the diet recently? ___ yes ___ no
4. Do you give your pet packaged treats? ___ yes ___ no
5. Do you feed your pet "human" food? ___ yes ___ no
Indicate if and how your pet's symptoms have affected his/her behavior and relationship with you.
1.Sleeps through the night:
___ always ___usually ___ occasionally ___ never.
2. Activity level:
___ inactive ___much less active ___ somewhat __ unchanged
3. Social behavior:
___ unsocial ___a lot less ___ somewhat ___ unchanged
social less social
4. Relationship changes:
___ fewer walks ___ no longer sleeps ____ interacts less
in same bed/room with family
1. Has your pet been treated for itching before? ___ yes ___ no
2. Indicate previous treatments administered to your pet. (check all
___ steroids ___ shampoos ___ sprays ___ ointments
___ antibiotics ___ hypoallergenic foods/diets ___ essential fatty acids
___ antihistamines ___ immunotherapy.
____ other (please specify) _________________________________________
(use back of page for additonal notes.)
Again, fill this form out as completely as possible and bring to the office with you for your appointment or fax to us at 423-2645. This history will be reviewed prior to the physical examination. Dr. Butler may elect to collect samples for laboratory testing. These may include
1. Ear swab- to identify bacteria, yeast, or ear mites
2. Skin scrapings/hair pluck analysis- to detect mange mites
3. Impression smear/tape preparation to identify other skin parasites, bacteria, and yeast.